THERAPEUTICS    OF 
THE    CIRCULATION 


FIRST  EDITION  .'  I  V  *7i  i  •  October  1908 
SECOND  EDITION  (5s.)  .  .  .  February  1914 
Reprinted  .  J  /i  1  *••  #«V  ™™ 


THERAPEUTICS    OF 
THE  CIRCULATION 

BY  SIR  LAUDER  BRUNTON,  BT. 

M.D.,  D.Sc.,  LL.D.(EoiN.),  LL.D.  (ABERD.),  F.R.C.P.,  F.R.S. 

CONSULTING)  PHYSICIAN   TO  8T  BARTHOLOMEW'S  HOSPITAL 

SECOND   EDITION 
WITH  ILLUSTRATIONS 


NEW  YORK 

PAUL    B.    HOEBER 

67-69    EAST    59TH    STREET 

1915 
1  Q  ^  Q  |  9' 


PREFACE 

THE  first  edition  of  this  book  consisted  of 
eight  lectures  delivered  in  the  spring  of  1905, 
at  the  request  of  Professor  Waller,  in  the 
Physiological  Laboratory  of  the  University  of 
London,  and  published  under  the  auspices  of 
the  University.  The  purpose  of  such  lectures, 
as  expressed  by  the  University  in  establishing 
them,  was  "  to  present  the  results  of  recent 
investigations  by  the  investigators  themselves." 
For  this  reason  my  own  work  on  the  circulation 
occupied  a  part  which  would  have  been  unduly 
prominent  in  an  ordinary  textbook.  The  lec- 
tures were  illustrated  by  experiments,  and  it  was 
sometimes  necessary  to  adapt  the  lectures  to  the 
experiments,  so  that  the  sequence  of  subjects 
was  not  so  orderly  as  it  would  otherwise  have 
been.  In  preparing  a  second  edition  I  have 
tried  to  avoid  both  of  these  faults,  and  have 
made  many  alterations  and  additions,  with  the 
object  of  increasing  the  practical  utility  of  the 
book.  The  arrangement  of  subjects  has  been 
altered,  the  matter  divided  for  greater  conven- 
ience into  chapters,  and  so  much  new  matter 
added  that  the  book  has  practically  been 
rewritten.  Delay  in  its  appearance  is  due  to 
the  fact  that  pressure  of  other  work  has  pre- 


vi  PREFACE 

vented  me  from  writing,  except  during  autumn 
holidays,  so  that  an  interval  of  more  than  ten 
months  occurred  between  writing  the  first  and 
second  parts,  and  a  similar  one  between  the 
second  and  third  parts.  When  the  lectures  were 
first  given  in  1905  the  measurement  of  blood- 
pressure  was  by  no  means  common  in  this 
country,  and  a  full  description  of  the  instruments 
used  to  measure  it  was  given.  It  is  now  so  com- 
monly employed  that  most  of  these  instruments 
have  been  omitted.  On  the  other  hand,  record- 
ing the  venous  pulse  and  electrical  examination 
of  the  heart  have  now  become  established  as 
practically  important,  and  a  short  account  has 
been  given  of  these  methods.  This  book  is  not 
intended  to  replace,  but  only  to  supplement  the 
usual  text-books  dealing  with  the  circulation. 
Much  space  is  therefore  devoted  to  physiology, 
to  pharmacology,  and  to  the  pathology  of  living 
structures  as  forming  a  basis  for  scientific  thera- 
peutics, but  morbid  anatomy  and  diagnosis, 
which  are  usually  dealt  with  at  great  length  in 
text-books  on  the  heart  and  circulation,  are 
barely  mentioned  here. 

I  may,  •  perhaps,  be  allowed  to  forestall  the 
very  obvious  criticism  that  this  book  contains 
much  physiology,  pathology,  and  pharmacology 
in  proportion  to  actual  therapeutics  by  pointing 
out  that  the  keystone  of  a  bridge,  which  makes 
it  passable,  is  quickly  placed  in  position,  but  it 
takes  a  long  time  to  build  the  piers  on  which  it 
must  rest ;  and  that  a  surgeon  may  only  take  a 
few  minutes  to  perform  an  operation,  but  needs 
years  to  learn  his  anatomy  so  thoroughly  that 


PREFACE  vii 

he  can  guide  his  knife  swiftly  and  surely  to  a 
successful  result. 

In  preparing  this  edition  I  have  consulted 
books  and  papers  by  Cushny,  Dixon,  Gaskell, 
Gottlieb,  Huchard,  Langley,  Lewis,  Mackenzie, 
Osier,  Schmiedeberg,  Waller,  and  others  too 
numerous  to  mention ;  but  I  have  received 
special  help  from  the  treatises  of  Gibson  and 
of  Hirschfelder  on  Diseases  of  the  Heart  and 
Aorta;  from  Kraus  and  Nicolai's  work,  Das 
Electro-Cardiogram  ;  from  Meyer  and  Gottlieb's, 
Experimentelle  Pharmacologie,  and  from  Tiger- 
stedt's  admirable  Lehrbuch  der  Physiologie  des 
Kreislaufs.  I  have  also  to  thank  my  friend 
Professor  Kronecker  most  heartily  for  his  kindly 
criticism  and  help,  and  to  express  my  very  great 
obligation  to  Dr  W.  J.  Dilling,  who  has  not  only 
revised  and  corrected  all  the  proofs  of  the  book, 
but  has  verified  the  references  in  the  literature 
of  the  first  fifteen  chapters  and  himself  supplied 
all  the  references  to  subsequent  chapters. 

Although  I  had  myself  verified  almost  every 
reference  in  the  first  fifteen  chapters,  by  reference 
to  the  original  work  or  paper,  yet  in  copying  my 
manuscript  so  many  errors  had  crept  in  that  the 
literature  would  have  been  untrustworthy,  whilst 
now  I  believe  it  is  correct,  and  will  be  a  great 
help  to  every  one  who  wishes  further  information 
in  regard  to  any  statement  made  or  subject 
mentioned  in  this  book. 


TO 
HUGO   KRONECKER 

M.D.,  D.Sc.  (CANT.),  LL.D.  (ABERD.  AND  GLASO.) 
ETC.,  ETC. 

I'ROFKSSOR  OF  PHYSIOLOGY  IN  HERNS,  LATE  DIRECTOR  OF  THE 
MAREY  INSTITUTE  IN  PARIS 

THE  AUTHOR  DEDICATES  THIS  BOOK 

IN   ACKNOWLEDGMENT    OF   THE    GREAT    SERVICES    HE    HAS    RENDERED  TO 

PHYSIOLOGY,  AND  ESPECIALLY  TO  THE  PHYSIOLOGY  OF  THE  CIRCULATION  ; 

IN      MEMORY     OF     MANY      PLEASANT      HOURS     SPENT      TOGETHER 

WHEN     WORKING     IN     LEIPZIG      UNDER     THE     DIRECTION     OF 

THEIR   BELOVED   MASTER,   CARL   LUUWIG,    IN    1869-70,  AND 

IN     TOKEN     OF     A     FRIENDSHIP     THAT     HAS      LASTED 

EVER  SINCE. 


CONTENTS 

CHAPTER   I 

GENERAL    PHYSIOLOGY  OF  THE    CIRCULATION 


PAGE 

Introduction  —  Harvey's  Discovery  —  The  Heart — 
Sleep  of  the  Heart — The  Arteries — Motor  and 
Peristaltic  Action  of  the  Arterioles  —  Lister's 
Observations — Capillaries  and  Veins — Self-mas- 
sage of  Arteries — Action  of  Fasciae — Accessory 
Muscles  of  Circulation — Lymph  and  Blood — 
Flow  of  Lymph  —  Arterial  Tension  or  Blood- 
pressure — Estimation  of  Blood-pressure — Regu- 
lation of  Blood  pressure — Co-ordination  of  Heart 
and  Blood-pressure — Arteries  and  Blood-pres- 
sure— Influence  of  the  Muscular  Area — Influence 
of  the  Splanchnic  Area — Distension  of  Liver 
— Cutaneous  Area — Cerebral  Area — Depressor 
Nerves  —  Independent  Pulsation  of  the  Vena 
Cava  and  Pulmonary  Veins  -..  :  \  •• ' ''  '•*-*•  * 


CHAPTER   II 

PHYSIOLOGY  OF  THE   HEART 

Movements  of  the  Heart — Heart  of  the  Frog — 
Origin  of  the  Cardiac  Rhythm — Neurogenic 
and  Myogenic  Theories — Block  Fibres — Differ- 
entiation of  Protoplasm — Origin  of  Stimuli  in 


CONTENTS 

FAOB 

the  Frog's  Heart—  Conduction  of  Stimuli  in  the 
Frog's  Heart — Heart-block — Are  the  Cardiac 
Nerves  Useless  ?  —  Comparison  between  the 
Heart  and  a  Medusa — Experiments  of  Romanes 
— Blocking  of  Stimuli  in  a  Medusa — Interference 
of  Waves — Inhibition — Inhibition  in  Medusa 
and  in  the  Turtle's  Heart — Inhibition  in  the 
Frog's  Heart  —  Action  of  Vagus — Inhibitory 
Ganglia  —  Stannius's  Experiments  —  Refractory 
Period  of  the  Heart — Experiments  of  Brunton 
and  Cash — Refractory  Period  of  the  Ventricle 
— Refractory  Period  of  the  Auricle — Stimulation 
of  the  Venous  Sinus — Extra  Systoles — Compen- 
satory Pause — Conduction  of  Stimuli  in  the 
Heart,  both  by  Muscle  and  Nerve — Practical 
Bearing  of  these  Experiments  .  «o;  .  25 


CHAPTER  III 

PHYSIOLOGY   OF   THE   MAMMALIAN   HEART 

Muscular  Structure  of  the  Mammalian  Heart  — 
Nature  of  the  Cardiac  Muscle  —  Intrinsic 
Nerves  of  the  Heart  —  Contraction  of  the 
Mammalian  Heart — Active  Dilatation  of  the 
Heart  —  Characteristics  of  the  Heart  — 
Origin  of  Stimuli  in  the  Mammalian  Heart — 
Nodes — Position  of  the  Nodes — Structure  of  the 
Nodes — Connections  of  the  Nodes — Bundle  of 
Stanley  Kent  and  His — Pacemaker  of  the  Heart 
— Nodal  Rhythm — Heart-block — Cause  of  Heart 
Block  in  Man — Functional  Heart-block — Noeud 
Vital  of  the  Heart — Kronecker  and  Schmey's 
Experiments — Fibrillation — Extrinsic  Nerves  of 
the  Heart — Functions  of  these  Nerves — Com- 
plex Functions  of  the  Vagus — Afferent  and 
Sensory  Nerves  of  the  Heart — Pain — Depressor 
Nerve — Mode  of  Action  of  the  Vagus  on  the 


CONTENTS  xi 

PAGE 

Heart — Opposite  Effects  of  the  Vagus  on  Heart 
Block — Trophic  Action  of  the  Vagus — Accelera- 
tor Nerves  of  the  Heart — Reflex  Stimulation  of 
the  Cardiac  Nerves  —  Reflex  Stimulation  of 
Inhibition — Valves  of  the  Heart — Sounds  of  the 
Heart— Double  Nature  of  the  Heart— Right 
Ventricle  .-  /  er  n-j'-n'  •*  '  .  •  50 


CHAPTER  IV 

PHYSIOLOGY  OF  VESSELS:    BLOOD-PRESSURE 

Aorta — Arteries,  Arterioles  and   Capillaries — Vaso- 

motor  Nerves — Dilating  Nerves — Elongation  of      J 
Muscle  ? — Contraction     of    Veins— Rhythmical    - 
Contraction  of  Vessels — Stimulation  of  Blood- 
vessels from  With  out — Stimulation  from  Within — 
Internal  Secretions — Toxins — Double  Function 
of  the  Kidney — Effect  of  Heat  and  Cold  on  the 
Systemic   Circulation— Fever — Effect  of   Heat 
and  Cold  on  the  Pulmonary  Circulation — Blood- 
Pressure — Schema  of  the   Circulation — Kymo- 
graphs— Blood-pressure  in  Animals — In  Man    .     84 


CHAPTER   V 

EXAMINATION   OF   BLOOD-PRESSURE   IN    MAN 

Measurement  of  Blood-pressure  in  Man — Instru- 
ments —  Sphygmomanometers  —  Bulb  Forms — 
Band  Forms — Standardisation  of  Aneroids- 
Method  of  using  Bulb  Sphygmomanometers — 
Fallacies — Use  of  Band  Sphygmomanometers — 


xii  CONTENTS 

PAOI 

Fallacies — Systolic  Pressure— Effect  of  Food- 
Effects  of  Exercise-  Effect  of  Emotion- Dias- 
tolic  Pressure  —  Measurement  of  Diastolic 
Pressure — Instruments — Relations  of  Systolic 
to  Diastolic  Pressure — Pulse-pressure — Signifi- 
cance of  Pulse-pressure  —  Size  of  Vessels — 
Measurement  of  Pressure  in  Veins — Measure- 
ment of  Pressure  in  Capillaries  .  .  .  100 


CHAPTER  VI 

EXAMINATION   OF  THE  CIRCULATION 

Cardiographs — Apex-beat  Cardiograms — Sphygmo- 
graphs — Carotid  Pulse — Mode  of  applying  the 
Sphygmograph  —  Sphygmograms  —  Fallacies — 
Inverted  Tracings — Venous  Pulse — Pseudo-pul- 
sations in  Jugular  Vein — Sphygmographic  trac- 
ing of  Venous  Pulse—Characters  of  the  Venous 
Pulse — Propagation  of  the  Pulse-wave — Delay — 
Practical  Use  of  the  Sphygmograph — X-Ray 
Examination  of  the  Heart — Skiagrams — String 
Galvanometer  —  Electro- cardiograms  —  Coagu- 
lometer — Viscosity  of  the  Blood  .  .  .123 


CHAPTER  VII 

PATHOLOGY  OF  THE  CIRCULATION 

Nutrition  of  the  Heart — Quality  of  Blood — Inflamma- 
tion— Endocarditis — Pericarditis  —  Myocarditis 
— Fatty  Degeneration — Circulation  in  the  Heart 
— Blocking  of  Coronary  Arteries — Self-massage 


CONTENTS  xiii 

PA  OK 

of  the  Heart — Nutrient  Action  of  Cardiac  Tonics 
— Self-massage  of  the  Arteries — Effect  of  Feeble- 
ness of  the  Heart  on  the  Nutrition  of  the  Blood- 
vessels— Feeble  Pulse — Effect  of  Emotion  on 
the  Vagus  Nerve — Nervous  Depression — Fatty 
Degeneration — Pulse  Rate — Effect  of  Position 
on  the  Pulse — Effect  of  Temperature — Effect  of 
Emotion  —  Tachycardia  —  Paroxysmal  Tachy- 
cardia— Exophthalmic  Goitre  —  Bradycardia — 
Paroxysmal  Bradycardia — Stokes-Adams'  Syn- 
drome—  Intermittent  and  Irregular  Pulse — 
Coupled  Beats  —  Bigeminal  Pulse  —  Extra 
Systoles — Pulsus  Paradoxus  and  Riegel's  Pulse  150 


CHAPTER   VIII 

SYMPTOMS  OF   DISORDERED  CIRCULATION 

Palpitation — Effect  of  Position  on  Palpitation — 
Abdominal  Pulsation — Throbbing  of  Arteries- 
Flushes  of  Heat — Shock — Shock  in  Surgery — 
Shock  from  Gastric  Disturbance — Syncope — 
Low  Blood-pressure  —  Breathlessness  —  Head- 
ache— Migraine — Sensibility  of  Arteries — Func- 
tional Sensory  Phenomena — Functional  Motor 
Phenomena— Sensibility  of  the  Heart — Pain  in 
the  Cardiac  Region — Angina  Pectoris — Patho- 
logy of  Angina  Pectoris  —  Claudication  and 
Angina  Pectoris — Views  of  Allen  Burns — Views 
of  Sir  Benjamin  Brodie — Angina  Abdominis 
— Cardiac  Dyspnoea — Raynaud's  Disease — Chil- 
blains—  Urticaria  —  Angio-neurotic  CEdema— 
Atheroma — High  Blood-pressure —  Insomnia — 
Giddiness  —  Senile  Rise  of  Pressure — Senile 
Decay — Embolism  and  Thrombosis  .  .  175 


xiv  CONTENTS 

CHAPTER   IX 

ORGANIC   DISEASES  OF   THE   HEART 

PAGE 

Altered  Sounds  of  the  Heart — Alteration  in  the 
Second  Sound — Accentuation — Gallop  Rhythm 
— Alteration  in  the  First  Sound — Cardiac  Mur- 
murs— Organic —  Functional  —  Dilatation  from 
Cardiac  Strain — Transient  Murmurs — Effects  of 
Aortic  Stenosis — Effects  of  Aortic  Regurgitation 
— Failing  Compensation  —  Secondary  Incom- 
petence— Effects  of  Mitral  Disease  on  Cardiac 
Rhythm — Mitral  Regurgitation  (organic) — Mit- 
ral Obstruction — Cardiac  Dyspnoea  —  Venous 
Engorgement  —  (Edema — Albuminuria — Flatu- 
lence— Ascites — Effect  of  Flatulence  on  Heart 
— Other  Forms  of  Cardiac  Disease — Vicious 
Circle  .  .  ,  .  .210 


CHAPTER   X 

METHODS  OF  TREATMENT   IN   CARDIAC 
DISEASE 

Uses  of  Treatment — Rest — Rules  regarding  Rest  for 
Patients  —  Position  —  Commodes  —  Massage — 
Results  of  the  combined  Use  of  Rest  and 
Massage  —  Graduated  Exercises  —  Oxygen  — 
Nauheim  Treatment — Baths  and  Exercises — 
Oertel's  Treatment— Diet— Sports— Milk  Diet— 
Chloride-free  Food — Sugar  Treatment  for  Fail- 
ing Heart — Means  of  Modifying  the  Circulation 
Locally  —  Heat  and  Cold  —  Fomentations  — 
Poultices — Local  Bleeding — General  Bleeding — 
Method  —  Tapping  for  OZdema — Tapping  for 
Ascites — Plasters  over  the  Heart — Blisters  .  232 


CONTENTS 


CHAPTER   XI 

ACTION   OF   CARDIAC  AND   VASCULAR 
REMEDIES 


Action  of  Drugs  on  the  Circulation — Its  Complexity 
— Means  of  Examining  the  Different  Factors — 
Investigation  of  the  Action  of  Drugs  on  the 
Frog's  Heart  —  Artificial  Circulation  through 
Mammalian  Vessels ;  through  the  Mammalian 
Heart — Examination  of  the  Effects  of  Poisons 
on  the  Heart  and  Vessels  in  the  Body — General 
Rules  regarding  the  Action  of  Drugs — Selective 
Action — Peripheral  and  Central  Action — Effect 
of  Dosage — Varying  Composition  of  Drugs — 
Condition  of  the  Body — Inurement — Tempera- 
ture— Season — Climate — Necessity  for  Care  in 
Drawing  Conclusions  —  Classification  of  Car-  J 
diac  and  Vascular  Remedies — Cardiac  Nutrients 
— Effect  of  Inorganic  Salts  on  the  Heart — Albu- 
minous Substances  —  Sugars  —  Purin  Bodies, 
Caffeine,  etc.  —  Cardiac  Tonics  —  Cause  of 
Normal  Tone  .  .  266 


CHAPTER   XII 


Cardiac  Stimulants — Digitalis — Historical  Sketch — 
Action  of  Digitalis  on  the  Frog's  Heart — Action 
of  Cardiac  Tonics  on  the  Embryonic  Heart — 
Action  of  Digitalis  on  Mammals — On  the  Mam- 
malian Heart — On  the  Arterioles — Stages  in 


xvi  CONTENTS 

PA3K 

the  Action  of  Digitalis — Toxic  Action  of  Digi- 
talis —  Action  of  Digitalis  on  the  Kidney — 
Re'sume'  of  the  Action  of  Digitalis — Uses  of 
Digitalis — Action  of  Digitalis  on  (Edema — Con- 
geners of  Digitalis — Differences  between  Digi- 
talis and  other  Cardiac  Tonics — Drawbacks  to 
the  Action  of  Digitalis  and  other  Cardiac  Tonics 
— Removal  of  these  Drawbacks — Digitalis  in 
Cases  of  Fatty  Heart— Action  of  Adrenalin  on 
the  Heart  and  Vessels — Action  of  Camphor- 
Action  of  Strychnine  on  the  Heart — Action  of 
Caffeine  and  other  Purin  Bodies  —  Action  of 
Pituitary  Gland  .  .  . ;';  ':>  fc  .  294 


CHAPTER   XIII 

ACTION   OF  CARDIAC   DEPRESSANTS/; 

Nicotine — Tobacco-smoking  -  Effects  of  Smoking — 
Attractions  of  Smoking — Excessive  Smoking — 
Aconite  ••"•»•'-  '  ». .  '^  « "'  '*' »  ••  *•••*•'•  .-323 


CHAPTER  XIV 

ACTION   OF  DRUGS  ON    BLOOD-VESSELS 

Drugs  acting  on  the  Blood-vessels  —  Vaso  motor 
Contractors  —  Peripheral  and  Central  —  Vaso- 
dilators— History  of  their  Discovery — Classes 
of  Vaso-dilators — Iodides  —  Effect  of  Drugs 
upon  the  Coronary  Arteries  !"i  .  •  332 


CONTENTS  xvii 

CHAPTER   XV 

ACTION    OF    DRUGS    ON    THE    URINARY, 
DIGESTIVE,  AND    NERVOUS   SYSTEMS 

PACK 

Drugs  acting  on  the  Kidneys,  Digestive  Organs, 
and  Nervous  System — Diuretics — Mercury  as 
a  Diuretic — Uses  of  Tapping  —  Purgatives — 
Mercurials — Gastric  Disinfectants — Swallowing 
Air — Alkalies — Sour  Milk — Intestinal  Disinfec- 
tants —  Carminatives  —  Adjuvants  to  Carmina- 
tives— Narcotics  .  ,  .  ".  .  346 

CHAPTER   XVI 

TREATMENT    OF    ACUTE   HEART    DISEASE 
AND  OF  CONVALESCENCE 

Treatment  of  Acute  Heart  Disease — General  Rules 
— Acute  Rheumatism — Microbic  Infection — Rest 
—  Clothing  —  Sponging  —  Diet  —  Medicines  — 
Flatulence  —  Elimination  —  Local  Applications 
— Poultices  —  Ice-bags  —  Leeches  —  Treatment 
of  Convalescence  .  ,  t  ^,66 


CHAPTER  XVII 

GENERAL    PRINCIPLES  OF  TREATMENT  IN 
HEART    DISEASE 

The  Heart  is  not  an  Isolated  Organ— Its  Efficiency 
Depends  on  Good  Quality  of  Blood — Require- 
ments for  this  —  Digestion  —  Assimilation — 
Metabolism — Excretion — Mastication — Gastric 

B 


xviii  CONTENTS 

PAOI 

Digestion — External  and  Internal  Secretions — 
Autocoid  Substances — Hormones — Chalones — 
Intestinal  Digestion — Absorption  and  Assimila- 
tion— Autointoxication — Action  of  the  Liver — 
Defecation — Metabolism — Exercise — Excretion 
— Bowels — Liver  — Kidneys— Skin  .  .  380 


Aortic     Stenosis  —  Aortic     Regurgitation  —  Mitral 
Stenosis — Mitral  Regurgitation  •    .  .  402 


CHAPTER   XIX 

TREATMENT    OF  SYMPTOMS  AND  FUNCTIONAL 
DISEASES 

Treatment  of  Symptoms  Occurring  in  Heart  Disease 
and  in  Functional  Diseases  of  the  Heart — Pal- 
pitation— Effect  of  Hot  Baths — Graves's  Disease 
— Tachycardia  from  Strain — Paroxysmal  Tachy- 
cardia— Bradycardia — Stokes-Adams  Disease — 
Faintness  and  Fainting— Giddiness — Shock — 
Sleeplessness  —  Causes  and  Treatment — Hyp- 
notics —  Intermittent  and  Irregular  Pulse — 
Cardiac  Pain  —  Treatment  of  an  Attack  of 
Angina  Pectoris — Diet  and  Regimen — Angina 
Abdominis  —  Cardiac  Asthma  —  Treatment  of 
Headache  —  Flushes  of  Heat  and  Morbid 
Blushing  —  Raynaud's  Disease  —  Chilblains- 
Low  Tension— High  Arterial  Tension — Treat- 
ment of  Senile  Conditions  of  the  Vessels — 
Cerebral  Haemorrhage— Cerebral  Thrombosis  .  411 

INDEX  .          .          .          .          .       \-.'»  |'       .  461 
INDEX  OF  AUTHORS  .          .          .       •  .          .  531 


LIST   OF   ILLUSTRATIONS 

PAQ« 

1.  Diagram  of  action  of  the  sigmoid  valves         kurtr        .      6 

2.  Diagram  of  the  effect  of  the  pulse  upon  the  flow  in    ... 

veins  and  lymphatics  .            .        erfsf..    'c.Jt-'  •     Io 

3.  Diagram  of  the  circulation      <  }*  n<.  :^-t .<i<     ••-,«.>•.<  •     *6 

4.  Diagram  of  the  frog's  heart         .           .            .  .26 

5.  Neuro-muscular  cells  .               .       ayit..  •.  .  ^^  ag 

6.  Diagram  of  heart-block   .             .        s;-,S5u.  ,mK(F-  '     32 

7.  Diagram  of  a  medusa      .        ,  v*^-,    -/.»,a/        «  -34 

8.  Diagram  of  two  sets  of  waves  reinforcing  each  other  .    36 

9.  Diagram  of  two  sets  of  waves  interfering   with  each 

other    .  .         ,->r..;     -r.          •  •  •     3^ 

10.  Diagram  of  two  sets  of  waves  interfering  with  each  other 

rhythmically   .  .  .  .  .  .     38 

11.  Diagram  of  Stannius's  experiment  .  .  .     41 

12.  Diagram  of  Stannius's  experiment          .  .  .    41 

13.  Effect    of   stimulating  the  frog's  ventricle — refractory 

period .          '.   -•        .  .  •  .  -43 

14.  Effect  of  stimulating  the  frog's  ventricle — reduplication     43 

15.  Effect  of  stimulating  the  frog's  ventricle — reduplication     43 

zix 


xx  LIST  OF  ILLUSTRATIONS 

MM 

16.  Effect  of  stimulating  the  frog's  auricle    .           -. .•-.  .    45 

17.  Effect  of  stimulating  the  frog's  venous  sinus      .  .     45 

18.  Fibrillation  in  the  heart  .            .            .            .  .51 

19.  Anterior  cardiac  plexus    .            .            .            .  -54 

20.  Purkinje's  fibres  .            .            .            .            .  -58 

21.  Noeud  vital          .         tijJ-    v-**         •  "^       I  w  •     62 

22.  Diagram  of  the  vagi  nerves         .            .            .  .69 

23.  Diagram  of  valves       -•     .  .      ....           .        ';•  .  .     74 

24.  Distended  and  contracted  ventricle         .- r     V   »••  •    75 

25.  Vaso-motor  nerves           .          •  .         •'  ,            .  -85 

26.  Transverse  contraction  of  muscle         -7  . '      •    ,"v  .     86 

27.  Simple  schema  of  the  circulation             •            •  '-"  .    95 

28.  Gaertner's  tonometer       .           .       **?/•»'  ••^ft;-  _  |O^ 

29.  Sphygmomanometer  with  armlet  and  aneroid     .  .  105 

30.  Method  of  standardising  aneroids           .            .  .  106 

31.  Effect  of  exercise  on  pulse  and  blood-pressure    .  .ill 

32.  Effect  of  pulse-rate  on  pulse-pressure      .        '0^-  .116 

33.  Effect  of  digitalis  on  pulse  and  blood-pressure   .  .  117 

34.  Relation  between  arterial  tension  and  pulse-pressure  .  118 

35.  Relation  of  ventricular  systole  to  the  aortic  pulse  .  124 

36.  Senile  pulse  and  ventricular  beat             .            .  .126 

37.  Sphygmographic  tracing  from  normal  pulse       .  .  129 

38.  Sphygmographic  tracing  of  aortic  regurgitation .  .  130 

39.  Sphygmographic  tracing  of  dichrotic  pulse     ••.^.,  •  131 

40.  Effect  of  cold  on  the  pulse        .;  ,;:        :,          ,.  .133 


LIST  OF  ILLUSTRATIONS  xxi 

PAGE 

41.  Modification  of  sphygmograms  by  altered  application  of 

the  sphygmograph     (^       <•-•..»  »•   'ft  it-        •  '33 

42.  Modification  of  sphygmograms  by  altered  application  of 

the  sphygmograph      .  .  .:•  .  .133 

43.  Modification  of  sphygmograms  by  altered  application  of 

the  sphygmograph      .          ".*        ".         '  ',iv'         .  134 

44.  Tracing  from  a  locomotive  artery        '"'."'  .    :  •  134 

45.  Tracing  from  a  locomotive  artery           .  ""  •''  .  134 

46.  Inverted  tracing  .            .            .""   ' '"',    '  ' '"f."  '!  .  135 

47.  Relations  of  the  jugular  pulse      .            .  '•  ii4''  .  137 

48.  Diagram  of  string  galvanometer .            .  l'  f  .  142 

49.  Diagram  of  electro-cardiogram    .            .  ."   '»"'  .  143 

50.  Electro-cardiogram  during  irritation  of  vagus     .  .  145 

51.  Diagram  of  Purkinje's  experiments         .  ;    .;«-..•  .  155 

52.  Diagram  of  self-massage  of  the  arteries  .  .<,  .156 

53.  Effect  of  massage  on  the  pulse    .         .  .,  •*•*:}-  •  157 

54.  Effect  of  emotion  on  the  pulse    •.         ••**•?!•  ••-,  .  164 

55.  Tracings  from  the  left  ventricle  and  aorta  .  •  166 

56.  Slow  pulse  in  a  Stokes-Adams  case        v  .„.<       11.169 

57.  Bigeminal  pulse  coming  on  during  observation  .  171 

58.  Diagram  of  shock             .    •        .i      -'    •.  .  .  178 

59.  Diagram  of  vessels  in  migraine   .             .  •  .184 

60.  Case  of  angina  pectoris — normal  pulse    .  .  .192 

61.  Case  of  angina  pectoris — during  angina      .  .  .  192 

62.  Case  of  angina  pectoris — during  severe  pain  .  .  192 

63.  Case  of  angina  pectoris — pain  relieved  by  amyl  nitrite  ;  192 


xxii  LIST  OF  ILLUSTRATIONS 

PAQI 

64.  Case  of  angina  pectoris — pain  removed  by  amyl  nitrite  .  192 

65.  Case  of  angina  pectoris — pain  coming  on  .  .  193 

66.  Case  of  angina  pectoris — pain  severe      .  .  .193 

67.  Case  of  angina  pectoris — pain  relieved    .        IV"."'         .  193 

68.  Brain  cell  devoured  by  macrophags       .  .  .  303 

69.  Renal  tubule  invaded  by  macrophags     .  .  .  203 

70.  Distribution  of  arteries  in  the  brain        .  .  .  205 

71.  Distribution  of  functions  in  the  brain      .  .  .  206 

72.  Irregular  pulse  of  mitral  disease ....  220 

73.  Diagram  showing  the  effect  of  flatulence  on  the  heart    .  226 

74.  Diagram  to  show  the  effect  of  the  supine  position   on 

respiration       .  .  .  '.' "    "'  •*'"'         .  235 

75.  Diagram  to  show  the  effect  of  the  upright  position  on 

respiration      .  .  .        r>vi«;J    !••>«!«        .  235 

76.  Effect  of  massage  and  movements  upon  the  pulse  .  240 

77.  Bottle  for  medicating  oxygen      .       ,  •:.    ;   -.-:^»,.  :  .242 

78.  Stopcock  for  artificial  respiration  with  oxygen    .  .  243 

79.  Effect  of  exercise  on  the  pulse — before   .  .  246 

80.  Effect  of  exercise  on  the  pulse — after      .         -**iy,  •  246 

81.  Effect  of  baths  on  the  pulse— before      ,*;.     :  lanlr.  •  246 

82.  Effect  of  baths  on  the  pulse — after  one  bath       r/s  -247 

83.  Effect  of  baths  on  the  pulse — saline  and  effervescing  .  247 

84.  Effect  of  baths  on  the  pulse — after  nineteen  baths  .  247 

85.  Method  of  securing  tubing  in  tapping  for  ascites  .  262 

86.  Apparatus  for  applying  drugs  to  the  frog's  heart  .  268 

87.  Apparatus  for  applying  drugs  to  the  vessels  of  verte- 

brates .  .  ,  .  .  .  .271 


LIST  OF  ILLUSTRATIONS  xxiii 

PAGE 

88.  Effect  of  barium   chloride   and  Liebig's  extract  on  a 

muscle  curve .        .  •  ,        ..          .  .  .  279 

89.  Effect  of  temperature  on  a  muscle  poisoned  by  veratrine  281 

90.  Effect  of  digitalis  on  pulse  and  blood-pressure .  .  299 

91.  Effect  of  stimulation  of  the  vagus  in  normal  animal     .  300 

92.  Effect  of  stimulation  of  the  vagus  in  an  animal  poisoned 

by  digitalis  ......  300 

93.  Stages  in  the  action  of  digitalis  ....  302 

94.  Pulse-tracing  in  poisoning  by  digitalis .  .  .  305 

95.  Pulse-tracing  in  poisoning  by  digitalis .  .  .  305 

96.  Pulse-tracing  in  poisoning  by  digitalis  .  .  .  305 

97.  Pulse-tracing  in  poisoning  by  digitalis  .  .  .  305 

98.  Pulse-tracing  in  poisoning  by  digitalis .  .  .  305 

99.  Diagram  of  the  effect   of  erythrophloeum    on    blood- 

pressure  and  secretion  of  urine          .  .  .  306 

too.  Effect  of  amyl  nitrite  on  blood-pressure  .  .  337 

101.  Diagram  of  the  circulation  in  the  kidney  •  .  348 

102.  Circulation  in  the  kidney  of  the  newt   .  .  .  348 

103.  Diagram  to  show  effects   of  venous   congestion   and 

urinary  pressure  on  the  glomeruli  of  the  kidney       .  352 

104.  Diagram  to  show  the  effect  of  ascites  on  the  kidney      .  352 

105.  Enterohepatic  circulation  ....  354 

1 06.  Reflex  irritation  of  the  vagus  from  the  stomach  •  358 

107.  Diagram  of  imperfect  teeth       .  383 

1 08.  Diagram  to  show  effect  of  gastric  congestion    .  .  390 

109.  Diagram  to  illustrate  chemical   changes  in  stomach 

during  secretion         .  ...  392 


xxiv  LIST  OF  ILLUSTRATIONS 

PAOB 

no.  Syncope  in  aortic  regurgitation.  .  -405 

in.  Diagrammatic  method  of   showing  the  time-relations 

of  the  pulses  and  heart  contractions  in  tachycardia  .418 


THERAPEUTICS    OF    THE 
CIRCULATION    g  : 

CHAPTER   I 

GENERAL    PHYSIOLOGY  OF  THE   CIRCULATION 

Introduction — Harvey's  Discovery — The  Heart — Sleep  of 
the  Heart  —  The  Arteries  —  Motor  and  Peristaltic 
Action  of  the  Arterioles — Lister's  Observations — 
Capillaries  and  Veins — Self-massage  of  Arteries — 
Action  of  Fasciae — Accessory  Muscles  of  Circula- 
tion— Lymph  and  Blood — Flow  of  Lymph — Arterial 
Tension  or  Blood-pressure — Estimation  of  Blood- 
pressure — Regulation  of  Blood-pressure — Co-ordina- 
tion of  Heart  and  Blood  -  pressure— Arteries  and 
Blood-pressure — Influence  of  the  Muscular  Area — 
Influence  of  the  Splanchnic  Area — Distension  of 
Liver — Cutaneous  Area — Cerebral  Area — Depressor 
Nerves — Independent  Pulsation  of  the  Vena  Cava 
and  Pulmonary  Veins. 

THE  subject  of  these  lectures  is  "  The  Thera- 
peutics of  the  Circulation  "  :  the  means  by  which 
we  can  put  right  anything  that  may  have  gone 
wrong  with  the  circulation.  If  I  were  to  hand 
my  watch  to  any  one  of  you  and  tell  you  it  was 
not  going  properly,  you  would  naturally  hand 
it  back  to  me  and  tell  me  to  take  it  to  a  watch- 


2      GENERAL  PHYSIOLOG  Y  OF  CIRCULA  TION 

maker  ;  because  you  know  nothing  of  the  way 
in  which  watches  are  built,  of  the  disorders  to 
which  they  are  liable,  or  the  way  in  which  to  put 
them  right.  In  the  same  way,  before  you  can 
put  anything  right  which  has  gone  wrong 
with  the  circulation,  you  must  know  something 
about — 

(1)  Its  normal  working,  or  physiology; 

(2)  The   disorders   to  which   it   is   liable,   or 
pathology ; 

(3)  The   means  by  which  we  can  act  upon 
it,  or  pharmacology ; 

(4)  The  indications   by  which  we   recognise 
the  particular  disorder,  or  semeiology ;  and 

(5)  The  methods  of  applying  our  remedies  to 
the  disorders  which  we  have  already  recognised, 
or  therapeutics. 

It  is  evident  that,  before  we  can  deal  with 
therapeutics  satisfactorily,  we  must  take  up,  to  a 
certain  extent,  the  other  subjects  upon  which  it 
depends ;  and  although  you  have  studied  them 
all  to  a  certain  extent  already,  I  think  it  will 
be  advisable  to  go  shortly  over  them,  more 
especially  as  I  shall  have  to  take  them  in 
definite  relation  to  their  practical  use,  instead 
of  merely  considering  them  as  scientific  subjects 
unconnected,  possibly,  with  practical  medicine. 
But  the  treatment  of  these  must  necessarily  be 
very  brief,  because  the  subject-matter  to  be  con- 
sidered is  very  great. 

Harvey's  Discovery. — There  is,  perhaps,  no 
discovery,  either  ancient  or  modern,  which  has 
had  such  a  far-reaching  influence  on  the  health 
of  human  beings  as  the  discovery  of  the  circula- 


HAR  VE  Y'S  DISCO  VER  Y  3 

tion  by  Harvey.  The  truth  of  this  discovery 
was  at  first  denied,  then  its  importance  was 
belittled,  then  it  was  attributed  to  other  men ; 
but  now  its  full  importance  is  recognised,  and 
the  claims  of  Harvey  to  the  discovery  acknow- 
ledged. When  we  look  at  Harvey's  work,  it 
seems  almost  incredible  that  for  so  many 
thousands  of  years  men  should  have  overlooked 
the  circulation.  When  we  read  Harvey's  own 
account  of  his  discovery,  it  seems  one  of  such 
amazing  simplicity  that  one  is  inclined  to  think 
that  nobody  could  have  helped  making  it  In  his 
own  words,  it  occurred  to  him  "  whether  there 
might  not  be  a  motion  (of  the  blood),  as  it  were, 
in  a  circle."1  That  it  did  go  round,  Harvey 
showed  by  the  blood  issuing  from  the  proximal 
end  of  a  cut  artery,  and  by  the  swelling  of  the 
veins  when  an  obstruction  was  put  between  the 
periphery  and  the  centre. 

One  of  the  great  reasons  why  the  blood  had 
been  supposed  not  to  go  round,  but  to  flow 
backwards  and  forwards,  probably  was  that  the 
ancients  looked  upon  the  arteries  as  conveying 
air  alone  instead  of  blood,  or  else  conveying  a 
mixture  of  air  and  blood.  They  seem  to  have 
come  to  this  conclusion  from  the  fact  that  the 
arteries  were  generally  found  empty  in  animals 
that  had  been  killed  for  sacrifice ;  and  the 
reason  of  their  emptiness  I  shall  discuss  later, 
on  p.  8. 

Physiology  of  the  Circulation. 
The  Heart. — The  great  motor  power  which 


4     GENERAL  PH  YS10LOG  Y  OF  C1RCULA  TION 

keeps  the  blood  moving  in  a  circle  is  the  heart, 
although  its  action  is  supplemented  by  other 
mechanisms  in  the  vessels  and  tissues.  We  are 
sometimes  accustomed  to  speak  of  this  "  unrest- 
ing" organ,  but  this  is  a  total  mistake.  The 
heart  rests  in  an  adult  more  than  thirteen  hours 
out  of  the  twenty-four  ;  the  time  of  rest  being 
the  diastole,  and  the  time  of  work  being  the 
systole.  With  a  pulse  of  70,  Edgren  determined 
the  duration  of  the  systole  to  be  0-379  seconds, 
and  of  the  diastole  0-483  seconds  (Schafer's 
Textbook  of  Physiology,  vol.  ii.,  p.  38).  The 
duration  of  the  cardiac  cycle  is  thus  0-379 
+  0-483  =  0-862  seconds,  and  the  time  occupied 
in  diastole  in  twenty-four  hours  is  therefore 
0-862  : 0-483  : :  24  :  13-44 — i.e.,  more  than  thirteen 
hours.  In  his  introduction  to  Human  Physiology 
(p.  5  2), Waller  gives  the  normal  work  of  the  heart 
as  nine  hours,  and  the  rest  as  fifteen  hours  daily. 
In  his  Oliver-Sharpey  Lectures  of  1913  he*  con- 
siders that  the  heart  which  works  at  this  rate  is 
ordinary,  that  one  which  works  eight  hours  is 
very  good,  and  that  one  which  is  working  over 
twelve  hours  a  day  is  in  a  bad  condition. 

Sleep  of  the  Heart. — We  may  say,  then,  that 
the  heart  practically  sleeps  more  than  the  brain 
or  the  body ;  but  the  great  distinction  between 
the  sleep  of  the  heart  and  that  of  the  brain,  is 
that  the  sleep  is  so  short  at  a  time.  There  are 
very  few  healthy  men  who  could  not  walk  a 
thousand  miles  in  six  weeks,  walking  a  little 
over  eight  hours  a  day  at  an  easy  pace,  and 
resting  for  the  remainder  of  the  period ;  but 
*  Lancet,  1913,  vol.  L,  p.  1520. 


WORK  AND  SLEEP  OF  HEART  5 

there  are  not  many  men  who  could  emulate  the 
feat  of  Captain  Barclay,  of  walking  a  thousand 
miles  in  a  thousand  hours,  because  the  frequent 
interruptions  to  their  sleep  would  exhaust  them 
completely  ;  and  still  fewer  are  there  who  could 
walk  a  thousand  miles  in  a  thousand  half-hours, 
as  has  been  done  by  various  men  since  Captain 
Barclay's  time.  In  such  trials  of  endurance  a 
man  usually  walks  two  miles  at  a  time,  the  first 
mile  at  the  end  of  one  hour  or  half-hour,  and  the 
second  at  the  beginning  of  the  next  hour  or 
half-hour.  Supposing  he  walks  at  the  rate  of 
four  miles  an  hour — i.e.  a  mile  in  a  quarter  of  an 
hour — he  gets  an  hour  and  a  half  for  sleep 
between  every  walk  when  doing  a  thousand 
miles  in  a  thousand  hours,  but  only  gets  one- 
third  as  much  sleep,  viz.,  half  an  hour,  between 
his  walks  when  doing  this  distance  in  a  thousand 
half-hours.  An  attempt  to  do  a  thousand  miles 
in  a  thousand  quarter-hours  is  obviously  impos- 
sible ;  if  a  man  walked  at  the  rate  of  four  miles 
an  hour  there  would  be  no  time  for  rest  at  all, 
the  whole  time  being  required  for  walking.  A 
little  time  might,  no  doubt,  be  gained  by  increas- 
ing the  pace;  but  this  would  of  itself  involve 
greater  exertion,  and  the  time  thus  gained 
would  be  quite  insufficient  for  recuperation. 

In  the  same  way,  when  the  heart  is  forced 
to  beat  more  quickly  than  normal,  it  becomes 
more  and  more  quickly  exhausted  the  higher 
the  pulse-rate  rises,  because  nearly  the  whole  time 
for  the  extra  work  is  taken  from  the  diastolic 
pauses  or  sleep  of  the  heart,  even  though 
the  systole  may  be  slightly  shortened.  Hence 


6     GENERAL  PH  YS1OLOG  Y  OF  CIRCULA  T10N 

the  importance  of  slowing  the  pulse-rate  by 
rest,  by  cold,  by  drugs,  or  by  other  measures, 
when  it  tends  to  become  too  rapid. 

Perhaps  it  may  be  as  well  here  that  I  should 
note  that  the  heart,  at  certain  periods,  is  resist- 
ant to  external  stimuli.  When  Captain  Barclay 
was  taking  his  sleep  between  his  walks,  he 
would  be  more  and  more  ready  to  respond  to  a 
chance  call  the  nearer  the  time  came  for  him  to 
begin  again  ;  but  while  actually  engaged  in  his 
walk,  he  would  be  too  much  intent  upon  his 
work  to  heed  a  call  from  anyone.  In  the  same 
way,  we  find  that  during  the  period  that  the 
heart  is  contracting  it  will  not  respond  to  a 
stimulus  which,  if  applied  immediately  after  its 
action  is  over,  would  cause  it  to  contract  again. 
This  period,  which  we  have  to  consider  later  on, 
is  called  the  refractory  period. 


Fio.  1.— Diagram  to  show  how  the  blood  under  pressure  in  the  aorta  is  shut 
off  from  the  rest  of  the  heart  during  diastole  by  closure  of  the  sigmoid 
valves,  a,  Auricle ;  ao,  aorta ;  v,  ventricle. 

The  Arteries :  their  Triple  Function. — Now, 

if  the  heart  is  only  acting  for  eleven  hours  out  of 

the  twenty-four,  and  is  entirely  cut  off  from  the 

aorta  by  the  closed  aortic  valves  (Fig.  i),  what 

9  force  is  carrying  on  the  circulation  during  the 


THE  ARTERIES  7 

whole  of  the  other  thirteen  ?  This  force  is  the 
elastic  recoil  of  the  arteries,  which  have  been 
stretched  by  the  blood  forced  into  them  during 
the  ventricular  systole,  but  which,  if  healthy, 
again  contract  during  the  diastole.  The  vessels 
thus  act  as  a  storage  of  energy ;  just  like  a  watch- 
spring  when  wound  up  every  night,  or  like  the 
water  driven  by  a  force-pump  into  a  high  tank 
from  which  a  house  or  town  can  be  supplied,  or 
like  the  elastic  bag  in  a  spray-producer. 

The  arteries  have  really  three  functions. 
They  not  only  act  as  (i)  storers  of  force,  as 
just  mentioned,  but  as  (2)  regulators,  and  as 
(3)  motors. 

Storage  Action. — This  is  chiefly  effected  by 
the  aorta  and  larger  arteries,  which  contain  a 
quantity  of  elastic  tissue. 

Regulating  Action. — Their  power  of  regulat- 
ing the  supply  of  blood  to  different  parts  of  the 
body  was  known  to  Harvey,  who  said  :  "  It  is 
manifest  that  the  blood  in  its  course  does  not 
everywhere  pass  with  the  same  celerity,  neither 
with  the  same  force,  in  all  places,  and  at  all 
times.  ...  In  fear,  and  under  a  sense  of  infamy 
and  of  shame,  the  face  is  pale ;  but  the  ears 
burn,  as  if  for  the  evil  they  heard  or  were  to 
hear."2  As  my  old  teacher,  Professor  Ludwig, 
used  to  put  it,  "  There  is  not  nearly  sufficient 
blood  in  the  body  to  fill  all  the  vessels  at  once, 
and  the  vaso-motor  system,  which  regulates 
the  size  of  the  arteries,  is  like  the  turncock  in 
a  large  town  who  turns  off  the  water-supply  to 
one  district  at  the  same  time  that  he  turns  it  on 
to  another " ;  just  as  in  Harvey's  observation, 


8     GENERAL  PH  YSIOLOG  Y  OF  C1RCULA  TION 

the  vessels  became  contracted  in  the  face  at  the 
same  time  as  they  became  dilated  in  the  ear. 
All  organs  when  functionally  active  require  a 
larger  supply  of  blood  than  they  do  when 
quiescent,  and  when  they  act  the  arteries 
supplying  them  dilate  so  as  to  allow  a  larger 
supply  of  blood  to  flow  to  them ;  when  their 
action  has  ceased,  the  arteries  again  contract. 

Motor  and  Peristaltic  Action  of  Arteries. 
The  motor  action  of  the  arteries  has  received 
less  attention  ;  but  it  is,  I  think,  very  important, 
and  is,  I  believe,  the  cause  of  the  emptiness  of 
the  arteries  after  death,  which  so  long  prevented 
Harvey's  discovery  from  being  made.  When 
working  under  Professor  Ludwig  in  1869,  he 
directed  my  attention  to  the  contractile  power 
of  the  arterioles  apart  from  any  nerve  centre, 
and  while  watching  their  movements  I  have 
sometimes  seen  a  regular  peristaltic  action  take 
place,  by  which  the  blood  was  driven  forward 
in  the  arteriole,  just  as  faecal  matter  would  be 
driven  forward  in  the  intestine.3  Such  action 
may  empty  the  arterial  system  after  death  (p.  3). 

Lister's  Observations. — Since  these  lectures 
were  given  I  have  found  that  similar  observa- 
tions had  been  previously  made  by  Lord  Lister, 
who  records  that  in  the  amputated  limb  of  a 
frog  the  artery  "was  sometimes  constricted  to 
absolute  closure  in  one  part  of  its  course,  and 
dilated  to  a  very  considerable  degree — e.g.  3^° 
— in  another  part.  More  commonly,  however, 
the  artery,  though  never  uniform  in  size  as 
in  health,  had  a  general  tendency  either  to 
moderate  constriction  or  dilatation.  The  varia- 


CAPILLARIES  AND  VEINS  9 

tions  occurred  frequently  during  the  twenty- 
four  hours,  and  on  one  occasion  I  saw  the  artery 
in  the  act  of  slow  contraction  at  one  part  driving 
the  blood  into  a  dilated  portion  at  a  little 
distance."4 

Capillaries  and  Veins. — From  the  arteries 
the  blood  passes  into  the  capillaries,  and  some 
of  its  liquid  parts,  with  a  few  white  corpuscles, 
leak  through  their  walls  to  supply  the  needs  of 
the  tissues,  while  the  remainder,  along  with  the 
red  corpuscles,  passes  into  the  veins. 

Plow  of  Blood  in  the  Veins. — As  Kronecker 
points  out,  the  hydrostatic  pressure  in  the 
vascular  system  tends  to  make  the  blood  in 
the  veins  rise  to  the  same  height  as  in  the 
arteries,  in  the  same  way  as  mercury  stands  at 
the  same  level  in  the  two  limbs  of  a  U-tube. 
This  makes  it  possible  for  the  blood  in  the 
veins  of  a  man  standing  upright  to  rise  from 
the  feet  up  to  the  heart,  a  distance  of  more  than 
3  feet,  while  the  actual  impulse  which  the  blood 
in  the  vena  inferior  receives  from  that  of  the  aorta 
is  about  5  millimetres.  It  is  evident  that  this 
impulse  would  be  barely  sufficient  to  carry  on 
the  circulation  and  bring  the  blood  back  to  the 
heart  again,  were  it  not  for  various  helping 
agencies. 

Assistant  Factors  in  the  Circulation. —  One 
of  these  is  the  suction  exerted  by  the  move- 
ments of  inspiration,  and  another  is  the  suction 
exerted  by  the  heart  itself  during  the  ventricular 
contraction,  which  at  the  same  time  that  it  drives 
the  blood  out  of  the  thorax,  and  through  the 
aorta,  sucks  it  in  from  the  great  veins  (p.  1 54). 

c 


io   GENERAL  PH  YS1OLOG  Y  OF  C1RCULA  T10N 

One  very  important  adjunct  to  the  heart  in 
keeping  up  the  venous  circulation,  is  inter- 
mittent pressure  upon  the  veins  from  without, 
aided  by  numerous  valves  in  the  veins  them- 
selves; so  that  while  each  pressure  pushes  the 
blood  a  little  onwards,  its  return  is  prevented. 
External  pressure  is  produced  by  muscular 
action.  Each  contraction  of  a  muscle  squeezes 
the  blood  and  also  the  lymph  out  into  the 
veins  and  lymphatics,  both  of  which  have  very 
numerous  valves  at  short  distances  apart.  But 
every  beat  of  the  arteries,  as  a  rule,  tends  also 
to  help  on  the  venous  blood,  for  the  arteries 
and  veins  usually  have  a  common  sheath  of 
unyielding  fibrous  tissue  (Fig.  2,  a),  and  each 


Fio.  2.— Diagram  to  show  the  effect  of  the  arterial  pulse  in  aiding  the 
onward  flow  of  venous  blood  and  lymph,  by  a  process  of  what  may 
be  called  self-massage.  A  is  an  artery  during  diastole.  V  is  a  vein 
tilled  with  blood.  8  is  the  fibrous  sheath  which  encloses  the  artery, 
the  vein,  and  the  lymph  space  around  them.  A'  is  the  artery 
distended  with  blood  by  the  ventricular  systole.  AR  the  sheath  8'  is 
unyielding,  the  distension  of  the  artery  forces  the  blood  out  of  the 
vein  and  the  lymph  out  of  the  lymph  space,  and  as  the  backward  flow 
of  both  is  prevented  by  the  valves  of  the  veins  and  lymphatics,  the 
circulation  is  increased  in  both. 

time  that  the  artery  is  distended  during  a 
ventricular  systole  it  tends  to  push  a  corre- 
sponding amount  of  blood  onwards  through  its 
accompanying  vein  (Fig.  2,  b\ 

Self-Massage    of   Arteries. — At     the    same 
time  the  vasa  vasorum  of  the  artery  itself  are 


ASSISTANT  FACTORS  IN  CIRCULATION  u 

affected  in  a  similar  manner,  and  each  pulsation 
of  the  heart  constitutes  a  kind  of  gymnastics 
of  the  arteries,  and    tends   to    preserve   their  h 
cohesion,  elasticity,  and  contractility. 

In  Ludwig's  first  experiments  with  artificial 
circulation  he  employed  blood  under  constant 
pressure,  but  found  that  as  the  experiment 
went  on  the  pressure  required  became  greater 
and  greater,  and  the  tissues  tended  to  become 
oedematous.  Hamel,  under  Kronecker's  direc- 
tion, found  that  more  blood  can  be  driven 
through  the  vessels  in  a  given  time  by  filling 
them  rhythmically  than  by  passing  a  stream 
through  them  under  constant  pressure.  They 
also  retain  their  healthy  properties,  and  oedema 
does  not  occur.6  ^ 

Action  of  Fasciae. — In  addition  to  these 
mechanisms,  however,  we  have  the  pressure 
exerted  upon  the  veins  by  the  fasciae  of  the 
limbs,  and  Braune  has  shown  that  when  the 
veins  are  stretched,  their  capacity  is  increased, 
and  they  suck  blood  into  them.  The  veins  of 
the  upper  limbs  are  most  stretched  when  the^ 
fists  are  clenched,  the  hands  bent  somewhat 
down,  and  the  arms  extended  and  pushed 
rather  backwards — the  very  attitude,  indeed, 
that  is  assumed  by  a  man  who  has  been  sitting 
for  a  length  of  time  at  a  writing-table  and  feels 
himself  cramped  in  consequence.  The  veins 
become  relaxed  when  the  leg  is  bent  and 
turned  slightly  inwards,  whilst  the  veins  become 
stretched  when  the  foot  is  turned  outwards  and 
the  leg  extended  and  pushed  somewhat  back- 
ward. The  first  of  these  positions  is  nearly  that 


1 2    GENERAL  PH  YSlOLOG  Y  OF  ClRCULA  T10N 

assumed  by  one  leg  when  we  advance  it  for  the 
purpose  of  walking,  and  the  second  when  we 
move  the  body  and  other  leg  forward.6 

Accessory  Muscles  of  Circulation.  —  The 
late  Professor  Sharpey  used  to  insist  a  good 
deal  upon  the  functions  of  the  rotators  of  the 
leg,  and  he  pointed  out  that  in  books  on 
anatomy  the  trunk  is  looked  upon  as  a  fixed 
point,  and  the  rotation  is  discussed  in  terms 
of  this ;  so  that  we  say  that  the  function  of 
the  tensor  vaginae  femoris  is  to  rotate  the  leg 
inwards  upon  the  body,  and  that  of  the  gluteus 
maximus  to  rotate  it  outwards.  In  reality, 
he  said,  when  the  foot  is  planted  on  the  ground 
it  is  the  leg  which  is  the  fixed  point  in  walking ; 
and  the  function  of  these  muscles  is  to  rotate 
the  body  on  the  leg,  the  tensor  vaginae  femoris 
rotating,  not  the  leg  inwards,  but  the  body 
outwards,  so  as  to  bring  the  centre  of  gravity 
over  the  foot.  But  in  view  of  Braune's  observa- 
tions these  muscles  acquire  a  new  value.  We 
speak  very  frequently  of  accessory  muscles  of 
respiration,  but  I  have  not  seen  anywhere  the 
tensor  vaginae  femoris  and  the  gluteus  maximus 
spoken  of  as  accessory  muscles  of  circulation, 
yet  both  they  and  the  muscles  of  the  calf 
and  thigh  may  well  deserve  such  an  appella- 
tion. 

Lymph  and  Blood.  —  The  old  expression, 
"  The  Blood  is  the  Life,"  is  true  to  a  certain 
extent,  for  when  the  circulation  of  the  blood 
ceases  the  body  dies ;  and  if  blood  be  kept 
circulating  artificially  in  any  part  of  the  body, 
it  may  be  kept  alive  for  hours  or  even  days 


L  YMPH  AND  BLOOD  13 

after  the  rest  of  the  body  is  dead  (Ueberlebende 
Organe,  of  Ludwig). 

And  yet  blood  itself  is  an  irritant,  and  when 
brought  into  immediate  contact  with  the  sub- 
stance of  muscles  and  nervous  ganglia,  it  injures 
them.7  It  is  the  tissue-juice  or  lymph  which 
nourishes  the  tissues,  and  in  it  they  live.  As 
Claude  Bernard  has  well  put  it,  we  live  in  a 
fluid  internal  medium.8  A  fish  swimming  in 
water  is  not  living  in  air  although  the  glass 
globe  in  which  the  water  is  contained  may  be 
standing  on  a  table  surrounded  on  all  sides  by 
air,  and  although  our  bodies  as  a  whole  are 
surrounded  by  air,  our  tissues  live  in  the  inter- 
cellular fluid  in  which  they  are  bathed,  in  the 
same  way  as  a  fish  lives  in  the  water.  But 
just  as  the  water  requires  to  be  aerated  and 
food  supplied  to  the  fish,  so  the  lymph  requires 
oxygen  and  nutriment,  and  these  it  receives 
constantly  from  the  blood  in  the  capillaries. 
Some  of  the  waste  products  of  tissue  metabolism 
probably  return  to  the  capillaries,  and  some 
are  carried  back  in  the  lymph  into  the  general 
circulation. 

One  of  the  most  important  of  all  the  waste 
products  is  CO2,  which  acts  as  a  poison  to  the 
tissues,  and  must  be  constantly  removed  from 
them.  Its  removal  is  effected  by  the  alkaline 
salts  in  the  serum.  All  tissues  and  animals 
are  not  equally  affected  by  CO2 ;  for,  according 
to  Kronecker,  goldfish  live  for  a  whole  day  in 
water  that  has  been  boiled,  then  cooled,  placed 
in  a  bottle  and  hermetically  sealed,  while  brook 
trout  die  in  a  few  minutes ;  and  many  people 


14    GENERAL  PHYS1OLOG  Y  OF  C1RCULA TION 

require  a  constant  fresh  supply  of  fresh  air, 
while  others  are  perfectly  comfortable  in  small, 
close  rooms. 

Flow  of  Lymph. — It  is  evident  that  any 
description  of  the  circulation  would  be  in- 
sufficient without  a  consideration  of  how  the 
lymph  flows,  for  the  circulation  of  the  lymph 
is  quite  as  necessary  as  that  of  the  blood  itself. 
Here  also  the  muscles  form  one  of  the  most 
efficient  sources  of  motor  power.  At  each 
relaxation  of  a  muscle  it  tends  to  cause  a 
vacuum  within  its  surrounding  fascia,  into 
which  the  lymph  flows  from  the  muscular 
structure.9  At  each  contraction  the  muscle 
presses  this  lymph  out,  and  these  alternating 
muscular  movements  really  act  as  a  subsidiary 
heart,  and  do  away  with  the  necessity  of  having 
in  mammals  the  lymph  hearts  which  are  seen 
in  the  frog. 

In  the  pleura  and  the  diaphragm  the  move- 
ments of  respiration  have  a  similar  pumping 
action  on  the  pleural  and  peritoneal  fluids.10 

It  may  seem  that  I  am  spending  too  much 
time  upon  points  in  the  circulation  which  you 
all  know,  but  I  shall  have  to  return  to  them 
again  in  discussing  Treatment,  and  unless  I  had 
put  them  before  you  now  in  the  way  I  have 
done,  you  might  not  be  so  readily  able  to  per- 
ceive the  reason  for  the  therapeutic  measures 
which  I  shall  afterwards  have  to  mention. 

Arterial  Tension  or  Blood-pressure. — During 
the  long  sleep  of  the  heart — thirteen  hours  out 
of  every  twenty-four — the  circulation  is  main- 
tained by  the  contractile  force  of  the  arteries, 


EST1MA  TION  OF  BLOOD-PRESS URE      1 5 

which  presses  the  blood  out  through  the  only 
opening  which,  in  health,  is  available,  namely, 
through  the  capillaries.  This  contractile  power 
is,  of  course,  to  a  great  extent,  due  to  elasticity, 
especially  in  the  larger  arteries,  although  in  the 
arterioles  it  is  probably  chiefly  due  to  con- 
tractility. The  force  with  which  the  blood 
would  be  pressed  out  if  a  vessel  were  opened  or 
a  cannula  put  into  it,  is  known  as  the  blood- 
pressure. 

Estimation  of  Blood-pressure. — It  is  usually 
estimated  by  connecting  an  artery  with  a  mer- 
curial manometer,,  and  seeing  the  height  of 
mercury  required  to  counterbalance  the  pressure 
in  the  vessels.  It  was  first  estimated  by  a 
clergyman,  the  Rev.  Stephen  Hales,11  who 
after  cutting  an  artery  in  an  animal,  and  con- 
necting a  glass  tube  with  the  artery,  noted  the 
height  to  which  the  blood  rose  in  the  tube. 
Poiseuille 12  improved  upon  this  plan,  by 
connecting  the  artery  with  a  mercurial 
manometer ;  and  an  immense  advance  was 
made  by  Ludwig,13  who  registered  the  move- 
ments of  a  mercurial  manometer  on  a  revolving 
cylinder.  To  this  recording  manometer  he 
gave  the  name  of  kymograph  (Fig.  3,  p.  16). 

Although  he  did  this  in  1847,  yet  in  1865, 
when  I  first  began  to  work  at  the  action  of 
drugs  on  the  blood-pressure,  there  was,  I  believe, 
not  a  single  recording  manometer  in  this 
country,14  and  it  was  only  at  this  time  that  one 
was  first  made  by  Sir  John  Burdon-Sanderson,15 
and  used  by  him  in  his  research  upon  the 
relationship  of  respiration  to  circulation.  It 


16   GENERAL  PHYS1OLOG  Y  OF  CIRCULA  TION 

was  just  a  little  before  this  that  Marey16  in- 
vented his  sphygmograph,  by  which  much 
interesting  information  has  been  gained  regard- 
ing the  circulation  in  man. 


FIG.  S.— Diagram  of  the  circulation,  a,  The  heart  completely  shut  oft 
by  the  valves  during  diastole  from  b,  tfie  arteries;  ••,  the  capillaries; 
(1,  the  veins;  r,  mercurial  manometer;  /,  a  float;  g,  a  recording 
cylinder. 

Regulation  of  Blood-pressure. — The  blood- 
pressure,  one  may  roughly  say,  depends  upon 
the  difference  between  two  factors,  viz.,  (i)  the 
amount  of  blood  pumped  by  the  heart  into  the 
cardiac  end  of  the  arterial  system  in  any  given 
time,  and  (2)  the  amount  running  out  of  the 
arterial  system  at  the  other  end  through  the 
capillaries  into  the  veins  in  the  same  time.  It  is 
obvious  that  unless  some  means  existed  by 
which  these  two  factors  could  be  brought  into 
proper  relationship,  much  mischief  might  be 
done. 

If  the  heart  were  to  continue  pumping  in 
blood  whilst  the  arterioles  were  tightly  con- 
tracted, the  pressure  would  rise  so  high  that 
either  a  vessel  would  burst,  as  it  does  in 
apoplexy,  or  the  heart  would  be  strained ;  or, 
as  Waller  has  shown,  the  left  auricle  might 
stop  altogether. 17  On  the  other  hand,  if  the 


HEARTS  ACTION  AND  BLOOD-PRESSURE  17 

arterioles  were  dilated  and  the  heart  did  not 
beat  more  actively,  so  as  to  supply  a  larger 
amount  of  blood,  the  arteries  would  become  so 
empty  and  the  pressure  in  them  so  low  that  the 
circulation  through  the  various  organs  would  be 
insufficient  to  maintain  their  functional  activity ; 
and  the  brain,  being  especially  sensitive,  syncope 
would  result. 

Co-ordination  of  Heart's  Action  and  Blood- 
pressure.  Centres  in  Medulla  Oblongata. — 
Co-ordination  is  maintained  by  means  of  the 
nervous  system,  the  chief  centre  of  which  is  in 
the  medulla  oblongata,  where  the  most  import- 
ant part  of  the  vaso-motor  centre  is  located,  and 
where  also  the  vagus  roots  are  situated.  By 
irritation  (a)  of  the  vagus  roots,  or  (£)  of  their 
trunks,  or  (c)  of  their  ends  in  the  heart,  the 
movements  of  the  heart  become  slower  and 
often  weaker ;  although  the  slowing  and  weak- 
ness may  occur  more  or  less  independently  of 
each  other.  Any  excessive  tension  in  the 
vessels,  involving  as  it  does  the  blood-supply  of 
the  medulla,  acts  as  an  irritant  to  the  vagus 
centre,  puts  the  vagus  nerve  into  action,  slows 
the  heart,  and  thus  prevents  the  tension  from 
rising  too  high.*  On  the  other  hand,  diminished 
pressure  in  the  arterial  system  lessens  the 
normal  stimulation  of  the  vagus  centre,  so  that 
the  vagus  nerves  act  less  powerfully  on  the 

*  Frangois  Franck  (Traveaux  du  labor atoire  de 
Marey,  1877,  vol.  iii.,  p.  276)  has  shown  this  in  a  brain 
kept  alive  by  artificial  circulation  and  separated  from  the 
rest  of  the  body,  except  that  the  vagi  remained  intact,  so 
that  the  brain  could  act  on  the  heart. 


1 8   GENERAL  PHYSIO  LOG  Y  OF  C1RCULA  T1ON 

heart,  its  beats  become  quicker,  and  the  pressure 
rises. 

Arteries  and  Blood-pressure. — On  the  other 

hand,  the   vaso-motor  centre,    when  in   action, 

causes  the  arterioles,  especially  of  the  intestines 

and  of  the  skin,  to  contract,  so  that  the  channels 

^by  which  the  blood  can  pour  from  the  arteries 

*into  the  veins  are  diminished  in  size,  and  the 

pressure,  consequently,  tends  to  rise. 

Effect  of  Anaemia  and  Suffocation.  —  All 
centres  in  the  medulla  oblongata  are  excited  by 
anaemia ;  the  vagus  roots,  the  accelerating 
centre,  the  vaso-motor  centre,  and  also  the 
convulsant  centres,  are  excited  by  anaemia  and 
suffocation  ;  but  in  such  conditions  the  inhibitory 
is  greater  than  the  accelerating  action,  so  that 
the  pulse  in  asphyxia  tends  to  become  slow. 

Influence  of  the  Muscular  Area. — All  arteries 
do  not  contract  equally  when  the  cervical  cord 
is  stimulated,  and  there  are  a  number  of  arteries 
which  are  only  slightly  influenced  by  the  vaso- 
motor  centre,  for,  when  this  centre  is  irritated  so 
as  to  contract  all  the  vessels  of  the  skin  and  intes- 
tines to  the  utmost,  blood  may  still  pour  through 
those  vessels  which  supply  the  muscles  so  rapidly 
that  the  effect  of  the  vaso-motor  centre  hardly 
appears  to  be  felt  at  all.18  Nevertheless,  Waller 
noticed  that  sometimes  by  stimulating  this 
centre  the  tension  may  rise  so  high  as  to  pre- 
vent the  left  auricle  from  beating ;  although 
Ewald  has  found  that  the  left  ventricle  of  a  dog 
is  capable  of  overcoming  four  times  the  normal 
pressure.19  These  different  results  depend,  of 
course,  upon  the  different  animals  experimented 


VASCULAR  AREAS  19 

upon  and  the  different  conditions  under  which 
the  experiments  are  made.  The  reserve  power 
of  the  healthy  ventricle  is  most  important,  and 
is  in  marked  contrast  to  its  condition  in  disease. 
Influence  of  the  Splanchnic  Area. — The 
four  largest  vascular  districts  in  the  body  are 
those  of  (i)  the  splanchnic  area,  (2)  the  muscles, 
(3)  the  brain,  and  (4)  the  skin.  It  is  the 
splanchnic  area  which  is  more  especially  under 
the  influence  of  the  vaso-motor  centre.  Any 
disturbance  of  the  circulation  in  this  area 
greatly  modifies  the  blood-pressure,  and  section 
of  the  splanchnic  nerves  will  reduce  it  enor- 
mously. The  splanchnic  area,  therefore,  serves 
toa  great  extent  as  a  regulator  of  blood-pressure ; 
and  when  the  portal  system  is  dilated  by  ligature 
of  the  portal  vein  and  aorta 20  the  whole  of  the 
blood  in  the  body,  or  at  least  a  large  part  of  it, 
will  collect  in  the  vessels  of  the  intestines  and  in 
the  liver ;  so  that,  to  use  Lud wig's  words,  "  an 
animal  may  be  bled  into  its  own  veins."  This 
occurs  in  sudden  death,  so  that  the  arteries  are 
empty  (vide  pp.  3,  8). 

Distension  of  Liver. — In  the  healthy  body 
we  do  not  notice  great  changes  in  the  liver, 
because  the  pressure  in  the  portal  system  underr 
goes  but  very  slight  alteration.  However,  when 
there  is  backward  pressure  from  the  heart,  in 
consequence  of  incompetency  of  the  tricuspid 
valves,  the  liver  sometimes  becomes  enormously 
large,  reaching  down  to  the  umbilicus,  or  even 
to  the  iliac  fossa,  and  may  again  become  smaller 
when  the  venous  pressure  is  relieved. 

In  1868  Ludwig21  and  one  of  his  pupils  made 


20    GENERAL  PHYSIOLOG  Y  OF  CIRCULA  TION 

some  experiments  upon  the  secretion  of  bile  by 
an  excised  liver,  through  which  a  stream  of 
blood  was  passed  artificially ;  and  on  making 
experiments  myself  a  year  or  two  later,22  I  was 
very  much  struck  by  the  enormous  distensibility 
of  the  liver.  One  is  misled  in  regard  to  this 
property  by  the  hard,  firm  appearance  of  the 
liver  after  death ;  but  during  life  the  liver  is 
more  like  a  sponge,  and  reacts  just  like  a  sponge 
to  the  slightest  difference  in  blood-pressure, 
swelling  up  as  the  pressure  increases,  and 
diminishing  as  the  pressure  falls. 

Cutaneous  Area. — Harvey's  observations  (p. 
7)  regarding  the  colour  of  the  face  and  ears, 
show  that  the  cutaneous  vessels  may  contract 
in  one  place  and  dilate  in  another.  As  a  whole, 
however,  the  cutaneous  vessels  tend  to  dilate 
when  those  of  the  splanchnic  area  contract,  and 
vice  versa.  On  this  account,  when  the  cutaneous 
vessels  are  dilated  by  warmth,  the  blood  is  with- 
drawn from  the  splanchnic  vessels  and  congestion 
is  relieved,  while  cold  to  the  skin  drives  the 
blood  into  the  intestinal  vessels.23  These  actions 
are  not  simply  due  to  mechanical  displacement 
of  blood  from  one  area  to  another,  but  are 
produced  reflexly  through  the  nervous  system.24 

Cerebral  Area. — The  existence  of  vaso-motor 
nerves  in  the  cerebral  arteries  has  been  denied, 
and  changes  in  the  cerebral  circulation  asserted 
to  be  simply  of  a  passive  nature  depending  on 
the  general  blood-pressure.  Nevertheless  it  is 
almost  certain  that  the  cerebral  vessels  contract 
and  relax  independently  of  those  in  other  parts 
of  the  body,  and  sometimes,  indeed,  relax 


INDEPENDENT  PULSATION  OF  VEINS  21 

while  others  contract,  and  vice  versa?**  Certain 
drugs  which  act  locally  on  vessels,  such  as 
adrenalin,  cause  the  cerebral  vessels  to  dilate 
while  they  cause  most  other  vessels  to  contract.26 

By  injecting  paraffin  into  the  cerebral  vessels 
so  as  to  measure  the  contents,  Kronecker, 
Marckwald,  and  Henriques  found  that  the 
arteries  of  the  brain  contained  very  little  blood, 
no  more  than  one-tenth  of  a  cubic  centimetre  in 
rabbits.27  At  the  same  time  the  flow  of  blood 
through  the  brain,  as  shown  by  the  capacity  of 
the  carotids  and  the  rate  of  flow  through  them, 
appears  to  be  very  considerable.28 

Depressor  Nerves. — As  I  have  already  men- 
tioned, when  the  tension  is  too  great  in  the 
heart  and  aorta,  it  acts  as  a  stimulus  to  nerves, 
starting  from  the  heart  and  aorta,  and  causing 
reflex  dilation  of  the  abdominal  vessels,  so  that 
the  tension  in  the  heart  is  thus  relieved.  These 
nerves  may  either  run  as  a  separate  nerve, 
known  as  the  depressor  nerve,29  or  may  be 
partly  incorporated  with  the  vagus  trunk30 
(p.  65). 

Independent  Pulsation  of  the  Vena  Cava 
and  Pulmonary  Veins. — All  through  the  venous 
system  the  circulation  is  steady  and  even,  until 
we  come  to  the  vena  cava  and  pulmonary  veins, 
when  we  find  that  these  vessels  may  have  a 
pulsatile  contraction  of  their  own,  like  that  of 
the  venous  sinus  in  the  frog.  This  action  of 
these  veins  had  apparently  been  lost  sight  of 
until  Fayrer  and  I  rediscovered  it  in  1874,  and 
we  could  not  then  find  any  mention  of  it  in  any 
of  the  ordinary  textbooks  on  physiology.31  It 


was,  however,  well  known  to  Meibomius,a2  to 
Haller,33  and  also  to  Senac,34  a  century  and  a 
half  ago,  and  we  have  since  found  it  had  been 
noticed  by  Colin35  a  year  or  two  before  our 
observation.  This  contraction  is  not  always 
present,  and  so  it  can  hardly  be  regarded  as  a 
constant  part  of  the  cardiac  pulsation.  It  is 
possible,  however,  that  in  some  pathological 
conditions,  such  as  mitral  stenosis,  it  may 
become  very  important. 


LITERATURE. 

1  Harvey's  Works,  Syd.  Soc.  Ed.  1847,  p.  46. 

2  Ibid.,  pp.  128  and  129. 

3  Lauder   Brunton,  Sitzungsb.  d.  k.  sack.   Gesellsch.  d. 

Wiss.,  1869,  p.  285  ;  Ludwig' s  Arbeiten,  1869,  P-  Io1- 

4  Lister,  Report  of  the  Meeting  of  the  British  Association, 

Dublin,  1857,  p.  114.  Reprinted  in  his  Collected 
Papers,  vol.  i.,  p.  39  (Oxford :  Clarendon  Press, 
1909).  Also  M.  Schiff,  Arch.  f.  physiol.  Heilk.,  1854, 
vol.  xiii.,  p.  527. 

5  Hamel,  Ztschr.f.  Biol.,  1889,  vol.  xxv.,  p.  474. 

0  Braune,   Beitrdge  z.   Anat.   u.   Physiol.  als  Festgabe, 
Carl  Ludwig  gewidmet,  1874,  p.  5. 

7  Kiihne,  Setschenow  und  Paschutin,  quoted  by  Hermann. 

Handb.  d.  Physioi.,  1879,  Bd.  i.,  Theil  i,  p.  103. 

8  Claude    Bernard,    Lemons   de    Pathologie    experiment. 

P-  439- 

9  Generisch,  Ludwigs  Arbeiten  for  1870,  p.  53. 

10  Dybkowsky,  Ludivtg's  Arbeiten  for  1866,  p.  40. 

11  Hales,  Statical  Essays,  London,  1733,  v°l-  "•>  P-  '• 

12  Poiseuille,    Magendie*s  Journ.    de    la  physiol.,    viii., 

p.  272,  1828  ;  ix.,  1829,  p.  343. 

13  Ludwig,    Arch.  f.    Anat.   u.   Physiol.,    1847,   p.    242, 

Taf.  x.,  xiv. 

14  Lauder     Brunton,    On     Digitalis,      1868    (London : 

Churchill) ;  and  Collected  Papers  on  Circulation  and 


LITERATURE  OF  CHAPTER  1  23 

Respiration^  First  Series,  1907,  pp.  52  and  104 
(London  :  Macmillan  &  Co.). 

15  Burdon- Sanderson,  Roy.  Soc.  Proc.,  xv.,  1867,  p.  391  ; 

Phil.  Trans.,  clvii.,  1867,  p.  571. 

16  Marey,  Mem.  Soc.  Biol.,  1859,  p.  281  ;  Compt.  rend., 

1860,  i.,  p.  634. 

17  Waller,  Archiv  f.  Anat.  u.  Physiol.,  physiol.  Abtg., 

1878,  p.  525. 

18  Ludwig  and  Thiry,  Sitz.  Ber.  d.  Wien.  Akad.,  1864, 

vol.  xlix.,  Abt.  ii.,  p.  45  ;  Ludwig  and  Hafiz,  Lud-wigs 
Arbeiten,  for  1871,  p.  106 

19  J.  R.  Ewald,  Berl.  Klin.  Woch.,  1885,  p.  834. 

20  Ludwig  and  Thiry,  op.  cit.  Claude  Bernard,  Lemons  sur 

lesproprie'te's  physiol.  des  liquides  de  forganisme,  1859, 

torn,  i.,  p.  196  ;  Kronecker  and  Gautier,  Rev.  de  Med., 

Oct.  1911,  p.  373. 
Ludwig  and  Schmulewitsch,  Ludwig1  s  Arbeiten,  3**r 

Jahrg,  1868,  p.  114. 
Lauder  Brunton,  Bur  don- Sanderson's  Handbook  for  the 

Physiological  Laboratory,  1873,  P-  5°5  e*  seq.j  and 

Lettsomian  Lectures,  1885,  in  Disorders  of  Digestion, 

p.  25. 

23  Heidenhain,  P  finger's  Archiv,  1870,  vol.  Hi.,  p.  504 

et  seq.,  and  1872,  vol.  v.,  p.  113;  Dastre  and  Moral, 
Systeme  nerveux  vasomoteur,  Paris,  1 884,  p.  330 ; 
and  Bayliss,  Journ.  of  Physiol.,  1893,  vol.  xiv., 
p.  SQ^etseq. 

24  Wertheimer,  Arch,  de  Physiol.,  1894,  p.  308  ;  Otfried 

M tiller,  Deutsch.  Arch.f.  klin.  Med.,  1905,  82,  p.  574. 

26  For  discussion  of  this  subject  and  references  to  litera- 

ture, vide  F.  Hofmann  in  Nagel's  Handbuch  d. 
Physiol.  Menschen,  vol.  i.,  p.  296,  Braunschweig, 
1909  ;  Roy  and  Sherrington,  Journ.  of  Physiol.,  1890, 
vol.  xi.,  p.  85  et  seq.j  Bayliss  and  L.  Hill,  Journ.  of 
Physiol.,  1895,  vol.  xviii.,  p.  334  et  seq. 
'®  D.  Cow,  Journ.  of  Physiol.,  1911,  vol.  xlii.,  p.  132. 

27  Kronecker,  verbal  communication. 

'•*  Cybulski,  quoted  by  Tigerstedt,  Lehrbuch  der  Physiol- 
ogic des  Kreislaufs,  p.  359. 

**  Ludwig  and  Cyon,  Ludwigs  Arbeiten  for  1866,  p.  128  ; 
Aubert  and  Roever,  Pfliiger's  Archiv,  1868,  vol.  i., 

p.  211. 


24  LITERATURE 

30  Roever,   Langenbacher    and   Finkelstein,   quoted    by 

Tigerstedt,  op.  «'/.,  p.  278. 

31  Brunton  and  Fayrer,  Proc.  Roy.  Soc.,  1874,  voL  xxii., 

p.  125  ;  and  Proc.  Roy.  Soc.,  1876,  xxv.,  p.  174. 
'M  According    to     Rollett    (Hermann's    Handbuch    der 
Physiologic,    vol.    iv.,    p.    153),   it    was    known    to 
Meibomius  in  1668,  and  to  Johannes  M  tiller  in  1835. 

33  Haller,  Elementa  Physiologica,  1757,  torn,  i.,  pp.  410 

and  399  ;  and  Memoires  sur  la  Nature  Sensible  et 
Irritable  des  Parties  du  Corps  Animal,  1756,  torn,  iv., 

p.  4- 

34  Senac,  Traitt  de  la  Structure  du  Caeur,  etc.,  second 

edition,  Paris,  1783,  torn,  ii.,  pp.  37  and  38. 

35  Colin,  Compt.  rend.,  1862,  torn.  Iv.,  p.  495. 


CHAPTER    II 

PHYSIOLOGY   OF   THE   HEART 

Movements  of  the  Heart — Heart  of  the  Frog— Origin  of 
the  Cardiac  Rhythm — Neurogenic  and  Myogenic 
Theories — Block  Fibres — Differentiation  of  Proto- 
plasm— Difference  between  Neurogenic  and  Myo- 
genic Theories — Origin  of  Stimuli  in  the  Frog's  Heart 
— Conduction  of  Stimuli  in  the  Heart — Heart-block — 
Gaskell's  Experiments — Are  the  Cardiac  Nerves 
useless  ? — Comparison  between  the  Heart  and  a 
Medusa  —  Experiments  of  Romanes — Blocking  of 
Stimuli  in  a  Medusa — Interference  of  Waves  — 
Inhibition — Inhibition  in  Medusa  and  in  the  Turtle's 
Heart— Inhibition  in  the  Frog's  Heart  —  Action  of 
Vagus — Inhibitory  Ganglia — Stannius's  Experiments 
— Refractory  Period  of  the  Heart — Experiments  of 
Brunton  and  Cash — Refractory  Period  of  the  Ven- 
tricle— Refractory  Period  of  the  Auricle — Stimula- 
tion of  the  Venous  Sinus  —  Extra  Systoles  — 
Compensatory  Pause — Conduction  of  Stimuli  in  the 
Heart,  by  Nerves  as  well  as  by  Muscle — Practical 
bearing  of  these  Experiments. 

Movements  of  the  Heart. — In  the  frog's  heart 
the  venous  sinus  contracts  first  and  drives  the 
blood  into  the  auricles.  In  the  mammalian  heart 
the  venous  sinus  is  absent ;  and  therefore  in  con- 
sidering the  movements  of  the  heart  we  begin 
with  the  auricle,  which  contracts  and  drives  the 
blood  into  the  empty  ventricle.  The  ventricle 


26  PHYSIOLOGY  OF  THE  HEART 

in  turn  drives  the  blood  onwards  into  its  corre- 
sponding artery,  the  pulmonary  on  the  right,  and 
the  aorta  on  the  left.  This  rhythmical  action 
continues  for  some  time  in  a  heart  after  its 
removal  from  the  body,  and  if  artificial  circula- 
tion be  kept  up  in  the  coronary  arteries  the 
excised  heart  may  continue  to  beat  for  hours  or 
even  days. 

The  movements  may  be  recorded  in  writing 
on  a  revolving  cylinder  by  levers  laid  on  the 
auricles  and  ventricle,1  or  connected  with  them 
by  hooks.2 

Heart  of  the  Frog. — The  heart  of  the  frog 
being  simpler  in  structure  than  the  mammalian 
heart,  and  more  easily  studied,  has  been  used  to 
a  great  extent  for  the  purpose  of  discovering 
the  causation  of  the  cardiac  movements.  It 

Left    auricle     and  -^v 

pulmonary  veins.  \  ^^.    ml     Sup.  vense  cavse  and  vagi  nerves. 

vVl    r**^«c^^  Venous  sinus  and 
Aortic  bulb.  "^vA    fl        JT         Remak's  ganglion. 
\~NV~rO  ]      Inferior  vena  cava. 

Bidder's  ganglia.         V        J  Ventricle. 

Fio.  4.— Diagram  of  the  frog's  heart. 

consists  of  the  venous  sinus,  two  auricles, 
one  ventricle,  and  the  aortic  bulb  (Fig.  4). 
The  vagi  nerves  pass  to  the  junction  of  the 
venous  sinus  and  auricle,  and  here  form 
a  plexus  or  ganglion,  known  as  Remak's.3 
From  this  two  nerves  pass  down  the  auricular 
septum  to  the  base  of  the  ventricle,  where  they 
end  in  two  ganglia,  known  as  Bidder's  ganglia.4 
There  are  also  ganglionic  cells  in  the  septum 


ORIGIN  OF  CARDIAC  RHYTHM  27 

between  the  auricles,  known  as  Ludwig's 
ganglion.6 

Origin  of  the  Cardiac  Rhythm. — Two  sets  of 
rhythmic  movements  are  necessary  to  life:  (i) 
the  cardiac,  (2)  the  respiratory.  The  origin  of 
the  respiratory  rhythm  is  in  a  nervous  centre  in 
the  medulla  oblongata,  and  when  this  centre  is 
destroyed,  or  its  connection  with  the  muscles  of 
respiration  is  severed,  the  respiratory  movements 
cease.  As  the  rhythmic  movements  of  the 
heart  continue  after  its  removal  from  the 
body,  it  is  evident  that  the  cause  of  its  rhythm 
must  be  situated  in  the  heart  itself. 

Neurogenic  and  Myogenic  Theories. — Until 
recently,  the  rhythmic  contraction  of  the  heart 
was  supposed  to  be  due  to  stimuli  originating 
in  nervous  ganglia  within  its  walls.  This  is 
known  as  the  neurogenic  theory.  Of  late  years 
this  has  been  denied,  and  the  rhythm  ascribed 
to  stimuli  arising  in  the  cardiac  muscle  itself. 
This  is  known  as  the  myogenic  theory. 

The  difference  between  these  two  theories 
has  been  so  clearly  and  briefly  stated  by 
Tawara,  that  I  cannot  do  better  than  translate 
his  words : — 

"The  myogenic  theory  assumes  that  the 
rhythmic  activity  of  the  heart  in  all  animals, 
both  in  their  embryonic  and  developed  condition, 
resides  in  the  cells  of  the  cardiac  muscle  them- 
selves, and  that  the  nervous  system  possesses 
merely  the  secondary  function  of  regulation. 
It  also  maintains  that  the  transmission  of 
stimuli  between  the  individual  parts  of  the 
heart  does  not  occur  through  nerve  fibres,  as 


28  PHYSIOLOGY  01-  THE  HEART 

the  neurogenic  theory  assumes  it  does,  but 
through  the  block  fibres."6 

Block  Fibres. — The  fibres  mentioned  under 
this  name  by  Tawara  as  conducting  stimuli 
from  one  part  of  the  heart  to  another,  and 
regarded  by  him  as  muscular,  might  also  be 
regarded  as  nervous,  for  they  really  consist 
of  protoplasm  only  partially  differentiated,  so 
that  it  may  combine  the  functions  both  of 
muscle  and  nerve,  although  it  may  not  contract 
so  perfectly  as  muscle,  nor  conduct  stimuli  so 
swiftly  as  nerve.  Purkinje's  fibres,  which  form 
part  of  the  conducting  paths  in  mammalian 
hearts,  are  examples  of  this  (Fig.  2o).7  The 
name  of  block  fibres  has  been  given  to  the 
conducting  path  between  auricles  and  ventricles, 
because  injury  to  them  blocks  the  transmission 
of  a  stimulus  from  the  auricles  to  the  ventricles.8 

Differentiation  of  Protoplasm. —  In  the  fresh- 
water hydra  some  of  the  cells  appear  to  have 
the  power  of  receiving  stimuli  and  al:=o  of 
contracting,  in  fact,  of  performing  the  functions 
of  both  nerve  and  muscle.  To  these  cells 
the  name  of  neuro-muscular  has  been  given9 

(Fig.  5).  . 

With  increasing  differentiation  the  nerve 
cells  acquire  greater  power  of  receiving  and 
emitting  stimuli,  and  the  nerve  fibres  of  con- 
ducting them,  but  the  fibres  lose  the  power  of 
contracting  almost  entirely,  though  the  nerve 
cells  still  retain  the  power  of  contracting  their 
dendrons. 

Muscle,  on  the  other  hand,  acquires  increased 
contractile  force,  but  loses  to  some  extent 


DIFFERENTIATION  OF  PROTOPLASM   29 

the  power  of  apparently  originating  stimuli, 
so  marked  in  nerve  cells.  Yet  this  power  is 
not  wholly  lost,  and  even  in  voluntary  muscular 


FIG.  5. — Neuro-muscular  cells  from  the  fresh-water  hydra,  a,  A  nenro- 
muscular  cell  seen  in  profile;  ft,  a  three-quarter  view;  c,  a  frontal 
view.  (After  Ranvier.) 

fibre  rhythmical  contractions  may  be  excited 
by  constant  stimuli.  Thus,  if  the  Sartorius 
muscle  from  a  frog's  leg,  in  which  the  motor 
nerves  have  been  poisoned  by  curare,  be  sub- 
jected to  a  constant  stimulus  by  immersion 
in  distilled  water  or  in  a  solution  of  sodium 
salts,10  it  will  contract  rhythmically  for  days. 
Yet  under  ordinary  circumstances  this  muscle 
will  only  contract  when  stimulated  by  its 
motor  nerve.  The  apex  of  the  frog's  heart, 
which  is  said  to  contain  no  nerve  cells,11  *  also 
ceases  to  contract  when  cut  off  from  the  rest 
of  the  organ  ;  but  if  it  be  subjected  to  a  constant 

*  It  contains  a  fine  network  of  nerve  fibres.  Compare 
nerves  of  arteries,  p.  85,  and  of  mammalian  heart, 
P- 54- 


30  PHYSIOLOGY  OF  THE  HEART 

stimulus  by  increased  pressure  from  within,  by 
electricity,12  or  by  chemical  irritants  from  with- 
out, it  will  contract  rhythmically.18 

Difference  between  Neurogenic  and  Myo- 
genic Theories.  —  The  question  between  the 
neurogenic  and  myogenic  theories  of  cardiac 
contraction  is  therefore  not  so  much  whether 
the  cardiac  muscle  can  contract  rhythmically  or 
not  without  nervous  stimuli,  but  whether  it  does 
so  under  ordinary  circumstances. 

Origin  of  Stimuli  in  the  Prog's  Heart.— 
In  the  frog's  heart  the  stimuli  which  cause 
rhythmical  contraction  originate  at  the  junction 
of  the  large  veins  and  the  venous  sinus,  and 
to  a  less  degree  at  the  junction  of  the  auricle 
and  ventricle.  According  to  the  neurogenic 
theory,  they  are  supposed  to  start  in  the  nerve 
cells  of  Remak's  and  Bidder's  ganglia  in  these 
places.  According  to  the  myogenic,  they  are 
supposed  to  originate  in  imperfectly  differenti- 
ated muscle  cells  at  the  same  points. 

Though  the  ganglion-free  apex  of  the  frog's 
heart  will  contract  rhythmically  on  the  applica- 
tion of  a  constant  stimulus,  yet  it  only  responds 
by  a  single  contraction  to  a  single  stimulation. 
But  if  the  ventricle  containing  Bidder's  ganglia 
is  stimulated  in  a  similar  way,  it  responds  by 
several  rhythmical  contractions ; 14  and  when  it 
is  subjected  to  such  chemical  irritants  as  have 
no  action  on  the  apex,  or  to  warmth  which 
is  also  without  action  on  the  apex,  it  responds 
by  a  series  of  contractions.16  These  as  well  as 
other  facts  show  that  although  the  muscle  of 
the  frog's  heart  does  possess  the  power  of 


CONDUCTION  OF  STIMULI  IN  HEART    31 

rhythmical  contraction  apart  from  any  ganglia, 
yet  it  is  from  the  ganglia  that  the  stimuli  to 
rhythmical  contraction  usually  proceed. 

In  regard  to  those  parts  of  the  heart  from 
which  the  stimuli  to  contraction  proceed,  it 
might  be  better  to  speak  of  conversion  rather 
than  of  origination  of  stimuli,  because  they 
probably  do  not  generate  a  new  stimulus,  but 
only  convert  a  constant  stimulus  into  arhythmical 
one,  just  as  the  ganglion-free  apex  responds 
to  a  constant  mechanical  or  chemical  stimulus 
by  rhythmic  contractions.  The  difference 
between  the  apex  which  is  without,  and  the 
sinus  which  contains  ganglia,  is  not  so  much  one 
of  kind  as  of  degree.  When  Stannius's  ligatures 
are  applied  under  oil,  so  that  the  heart  is  not 
exposed  to  the  stimulus  of  the  air,  the  ventricle 
only  contracts  when  Bidder's  ganglia  are  stimu- 
lated by  the  application  or  removal  of  the 
ligature.16 

Conduction  of  Stimuli  in  the  Heart. — Accord- 
ing to  the  neurogenic  theory,  the  stimuli  are 
transmitted  from  the  venous  sinus  to  the  auricle, 
and  from  the  auricle  to  the  ventricle,  by  nerve 
fibres ;  but  the  quotation  I  have  already  given 
from  Tawara  (p.  27)  shows  that  those  who  hold 
the  myogenic  theory  entirely  deny  this  trans- 
mission by  nerve  fibres,  and  assert  that  it  occurs 
only  through  the  block  fibres  already  mentioned, 
and  through  the  muscular  fibres  of  the  heart 
itself.17 

Heart -block.  Gaskell's  Experiments. —  It 
was  discovered  by  Gaskell  that  when  the  frog's 
heart  is  placed  in  a  clamp,  the  jaws  of  which  lie 


32  PHYSIOLOGY  OF  THE  HEART 

in  the  groove  between  the  auricles  and  ventricle, 
no  alteration  occurs  in  the  beats  so  long  as  the 
clamp  exerts  no  pressure  on  the  heart.  But  as 
the  jaws  of  the  clamp  are  gradually  tightened 
the  cardiac  rhythm  becomes  altered  so  that 
instead  of  the  ventricle  beating  at  the  same  rate 
as  the  auricle,  it  may  only  beat  once  (Fig.  6)  for 
every  two  beats  of  the  auricle,  then  for  every 
three,  then  for  every  four,  and  so  on.18  The 
compression  seems  to  block  the  passage  of 


T  T   T   «*• 
a-  ~b 

Fio.  6.  —  Diagram  to  illustrate  Gaskell's  experiment  of  cardiac  block.  At 
a  the  jaws  of  the  clamp  hold  the  heart  without  compressing  it,  and 
each  beat  of  the  auricle  is  succeeded  by  one  of  the  ventricle,  as  shown 

by  the  figure  -L.    At  b  the  heart  is  compressed,  and  its  rhythm 

disturbed,  so  that  one  beat  of  the  ventricle  only  occurs  for  several  of 
the  auricles.  This  is  indicated  by  the  Roman  numbers,  the  upper 
line  of  which  shows  the  number  of  auricular,  and  the  lower  of  ventri- 
cular beats. 

stimuli  from  the  auricles  to  the  ventricle,  until 
they  have  accumulated  sufficient  strength  to 
force  their  way  in  spite  of  the  obstacle.  To 
this  condition  the  name  of  heart-block  is 
applied.  The  same  result  is  obtained  by 
partially  dividing  the  fibres  connecting  the 
auricle  and  ventricle. 

Are  the  Cardiac  Nerves  useless  ?  —  The 
myogenic  theory  easily  explains  the  rhythm  of 
the  heart  and  heart-block  so  far,  but  there  are 
other  phenomena  which  are  not  easily  explic- 
able, except  on  the  hypothesis  that  both  nerves 
and  muscle  participate  in  the  cardiac  rhythm. 


ARE  THE  CARDIAC  NERVES  USELESS?   33 

The  nerves  in  the  heart  are  extraordinarily 
abundant,  and  in  order  to  explain  what  I  believe 
to  be  their  object  I  may  perhaps  be  allowed  to 
employ  a  simple  comparison.  A  railway  train, 
when  once  started,  usually  proceeds  from  station 
to  station  without  interference ;  but  alongside  the 
rail,  or  overhead,  run  the  telegraph  wires,  and  at 
any  station  the  progress  of  the  train  may  be 
stopped  by  a  message  sent  by  the  telegraph. 
You  will  notice  also  that  in  many  railways  an 
electric  bell  rings  before  the  train  actually 
appears,  so  that  all  preparations  may  be  made 
for  its  arrival.  In  the  heart  the  transmission  of 
stimuli  by  the  cardiac  muscle  would  correspond 
to  the  passage  of  the  train ;  the  transmission  by 
the  nerves  would  correspond  to  the  telegraph, 
by  which  the  movement  of  the  ventricle  might 
either  be  stopped,  even  after  an  impulse  had  been 
sent  on  from  the  auricle  (Fig.  22,  p.  69),  or,  on  the 
other  hand,  the  ventricle  might  be  prepared  to  re- 
spond more  quickly  to  the  stimulus  passing  from 
the  auricle.  The  advantage  of  such  a  preparation 
is  evident  from  Romanes's  experiments  on 
medusae,  in  which  stimuli  did  not  always  produce 
the  proper  effect  unless  they  had  been  preceded 
by  another  stimulus  which  prepared  the  proto- 
plasm to  react. 

Comparison  between  the  Heart  and  a 
Medusa.  Experiments  of  Romanes.  —  The 
nervous  and  muscular  structures  of  the  heart 
are  very  intimately  related,  so  that  it  is 
extremely  difficult  to  determine  the  part  played 
by  each,  and  it  is  easier  to  observe  the  relation- 
ship between  protoplasm  and  nerves  in  the 


34  PHYSIOLOGY  OF  THE  HEART 

medusae,  or  jelly-fish,  where  they  can  be  more 
easily  separated,  and  thus  gain  some  light  upon 
the  function  of  each  on  the  heart.  A  number 
of  observations  were  made  upon  medusae  by 
Romanes.  A  medusa  consists  of  a  bell-shaped 
piece  of  contractile  protoplasm,  from  the  centre 
of  which  a  polyp  descends,  and  round  the  margin 
of  the  bell  is  a  nervous  gangliated  chain  and  a 
fringe  of  mobile  tentacles  (Fig.  7).  For  the 


Strip  of  contractile 
tissue  with  fringe 
of  tentacles 


Pio.  7.— Diagram  of  a  medusa  (Tiaropsis),  about  one-third  natural  size, 
with  a  strip  of  contractile  tissue  cut  from  the  bell,  but  left  attached 
at  one  end. 

purpose  of  description,  we  may  put  the  polyp, 
for  the  present,  out  of  account,  and  if  we  invert 
the  bell  we  find  that  it  bears  a  very  close 
resemblance  to  the  ventricle  of  the  frog,  which, 
like  it,  consists  of  a  contractile  portion  with 
ganglia  at  its  margin.  When  the  complete 
medusa  is  placed  in  sea-water,  the  bell  contracts 
rhythmically,  just  like  a  heart.19  When  the 
nerves  are  removed  by  cutting  off  the  marginal 
strip  which  contains  them,  the  bell  ceases  to 
contract ;  but  it  will  recommence  if  a  constant 


HEART  AND  MEDUSA  35 

stimulus,  either  chemical  or  electrical,  be  applied 
to  it.20  In  this  respect  it  completely  resembles 
the  apex  of  the  frog's  heart.  Moreover,  when  a 
stimulus  is  first  applied  it  may  not  appear  to 
act,  but  when  applied  several  times  the  con- 
tractions it  induces  are  stronger  and  stronger 
up  to  a  certain  maximum,  so  as  to  produce  the 
appearance  of  a  staircase — a  phenomenon  which 
was  also  observed  by  Bowditch  in  the  case  of 
the  heart21  When  a  strip  of  medusa  contain- 
ing the  ganglia  is  detached  only  at  one  end 
from  the  animal  and  is  left  attached  at  the 
other,  irritation  of  the  strip  will  cause  a  wave  to 
pass  along,  which  is  of  two  kinds.22  The  first  is 
that  of  contraction  in  the  protoplasm,  and  the 
other  is  a  nervous  stimulus,  which  makes  itself 
evident  by  the  movements  of  the  tentacles. 
These  waves  generally  pass  together,  the  nervous 
wave  being  usually  a  little  in  front  of  the  con- 
traction-wave ;  but  it  may  also  occur,  as  is 
shown  by  the  movements  of  the  tentacles,  with- 
out any  contraction-wave  in  the  protoplasm  of 
the  strip.  This  nervous  wave  is  more  easily 
excited  than  the  contraction-wave,  so  that  it 
may  be  started  by  stimuli  which  are  too  slight 
to  affect  the  contractile  substance,  the  ganglia 
apparently  being  more  sensitive  than  the  proto- 
plasm. For  this  reason  also  when  the  nervous 
wave  reaches  the  bell  it  will  cause  it  to  contract 
if  the  ganglia  are  still  present  in  the  bell ;  but  if 
these  have  been  removed,  the  nervous  wave  has 
not  the  power  to  stimulate  the  protoplasm  of 
the  bell,  which,  consequently,  remains  motion- 
less.23 


36  PHYSIOLOGY  OF  THE  HEART 

Blocking  of  Stimuli. — The  passage  of  stimuli 
along  the  strip  of  medusa  may  be  hindered  or 
prevented,  as  in  the  heart,  by  compressing  it,  by 
partially  dividing  it  so  as  to  narrow  it,  or  by 
straining  it  so  as  to  injure  it ;  or  by  poisons,  such 
as  chloroform,  ether,  alcohol,  strychnine,  and 
curare.  As  one  would  expect  from  different 
kinds  of  injury,  sometimes  the  contraction-wave 
is  blocked  first  and  sometimes  the  nervous 
wave.  When  the  block  is  only  partial,  it  may 
happen  that  several  of  these  waves  come  up  to 
it  before  one  can  pass  across,  just  as  in  heart- 
block.24 

Interference  of  Waves. — In  order  to  explain 


Fio.  8.— Diagram  of  two  sets  of  waves       Fio.  9. —Diagram  of  two 
reinforcing  eaeh  other,  so  as  to  pro-  sets  of  waves  interfering 

dace  a  doable  effect.  with  each  other. 

some  of  the  phenomena  of  inhibition  in  medusa 
and  in  the  heart,  it  may  be  well  to  refer  to  the 
interference  of  waves  in  general.  When  two 
sets  of  waves  travelling  from  the  same  point, 
and  at  the  same  rate,  combine  so  that  the  crests 
and  hollows  of  the  waves  in  each  set  coincide, 
the  height  of  the  waves  becomes  double  what  it 
was  before  (Fig.  8).  But  if  one  set  of  waves 
should  be  thrown  half  a  wave-length  behind  the 
other,  the  crests  of  one  set  will  fill  up  the  hollows 


INTERFERENCE  OF  WAVES  37 

of  the  other,  and  there  will  be  no  wave  at  all 
(Fig.  9).  This  phenomenon  is  said  actually  to 
occur  in  the  harbour  of  Batscha,  where  there  are 
two  channels,  one  of  which  is  slightly  longer 
than  the  other.  It  is  just  enough  to  throw  the 
set  of  waves  travelling  through  it  half  a  wave- 
length behind  those  travelling  through  the  other, 
so  that  when  they  meet  the  water  becomes 
perfectly  still.26  The  same  occurs  with  sound, 
so  that  two  tones  may  destroy  each  other.  In 
the  winter  of  1861-2  I  witnessed  Professor 
P.  G.  Tait  show  the  marvellous  experiment  of 
two  lights  making  darkness.  So  far  as  I 
recollect  this  was  done  by  throwing  two  equal 
beams  of  sunlight  upon  a  wall.  One  of  these, 
however,  was  passed  through  a  plate  of  tourma- 
line, which  threw  the  waves  of  light  in  this  beam 
nearly  half  a  wave-length  behind  those  in  the 
other.  By  means  of  a  prism  this  beam  could  be 
thrown  upon  the  other.  When  this  was  done 
the  spot  of  light  on  the  wall,  instead  of  becoming 
brighter,  was  eclipsed,  and  when  the  experiment 
was  finished,  instead  of  two  bright  spots  of  light 
on  the  wall  there  was  only  one,  much  dimmer 
than  either  had  been  before.  Had  the  one  beam 
been  exactly  half  a  wave-length  behind  the 
other,  instead  of  only  nearly  so,  there  would 
have  been  no  light  at  all. 

If  the  retardation  of  one  beam  is  still  greater, 
so  that  it  falls  a  whole  wave-length  behind  the 
other,  the  crest  of  the  waves  will  again  coin- 
cide, and  they  will  again  reinforce  instead  of 
interfering  with  each  other.  If  the  waves 
are  of  different  lengths,  they  will  sometimes 

_£    f^    **    f\     ,1    t~a 

1 3  \j  $  i  2 


38  PHYSIOLOGY  OF  THE  HEART 

strengthen  and  sometimes  weaken    each  other 
(Fig.  10)  • 

Inhibition. — By  this  term  is  usually  meant 
the  prevention  of  a  movement  which  would 
otherwise  occur.26  Inhibition  may  be  produced 
in  different  ways.  Thus  the  hand  may  be  kept 
motionless  although  the  biceps  is  contracting 
strongly,  and  would  bend  the  elbow  at  once,  if 
the  triceps  did  not  contract  at  the  same  time 
sufficiently  to  counteract  the  biceps.  But  the 
hand  may  also  remain  motionless  and  both  these 


FIG.  10.— Diagram  showing  the  effect  of  interference  of  two  systems  of 
different  wave-lengths,  the  dotted  line  in  A  with  4  waves  to  7  of  the 
complete  line.  The  resultant  ia  shown  in  B.  (From  Ganot's  Physics.) 

muscles  remain  inactive  even  when  the  hand  is 
pricked  or  injured,  and  would  naturally  be 
moved  if  the  will  of  its  owner  did  not  prevent 
it.  In  this  case  the  inhibition  occurs  in  the 
central  nervous  system,  and  the  exact  way  in 
which  it  does  so  is  not  at  present  known, 
although  it  is  probably  due  to  interference  of 
some  sort  between  nervous  impulses. 

*  Alex.  Forbes  has  produced  rhythmical  contraction  of 
voluntary  muscle  reflexly  by  concurrent  stimulation  of 
excitatory  and  inhibitory  nerves. — Roy.  Soc.  Proc.,  1912, 
vol.  Ixxxv.,  p.  2^2. 


INHIBITION  IN  HEART  39 

Inhibition  in  Medusae  and  in  the  Turtle's 
Heart. — It  has  been  found  by  A.  G.  Mayer* 
that  a  strip  of  the  sub-umbrella  of  a  scypho- 
medusa,  cut  in  the  shape  of  a  ring,  will  continue 
to  pulsate  rhythmically  if  a  contraction-wave  be 
once  started  in  it.  This  may  be  done  by  the 
application  of  various  chemical  or  electrical 
stimuli.  The  contraction  arises  at  the  point  of 
stimulation,  wherever  this  may  be.  It  may 
spread  from  this  point  as  two  waves  travelling 
in  different  directions  round  the  ring.  If  they 
are  equally  strong  they  block  each  other  when 
they  meet,  and  all  movement  ceases  until  a 
new  stimulus  is  applied  and  a  new  contraction 
started.f  But  if  one  is  stronger  than  the  other  it 
goes  on,  while  the  weaker  wave  is  obliterated.27 

The  ventricle  of  the  Loggerhead  Turtle's  heart 
when  cut  into  rings  behaves  in  a  similar  manner.28 

Inhibition  in  the  Frog's  Heart.  Action  of 
the  Vagus.  —  In  1845  .  the  brothers  Ernest 
Heinrich  and  Eduard  Weber  discovered  that, 
in  the  frog,  electrical  irritation  of  the  medulla 
oblongata,  or  of  the  vagus  nerves  which  pass 
from  it  to  the  heart,  causes  both  the  auricles 
and  ventricle  to  cease  beating  and  to  stand  still 
in  diastole.29  This  stoppage  they  attributed  to 
action  of  the  vagi  nerves  upon  those  nervous 
structures  in  the  heart  which  were  regarded  as 

*  A.  G.  Mayer,  advance  print  from  the  Proceedings  of 
the  Seventh  International  Zoological  Congress,  Boston, 
1 9th  to  24th  August  1907. 

t  M.  Schiff  found  that  peristaltic  waves  may  be  pro- 
duced in  voluntary  muscle,  and  that  these  may  cross  each 
other  without  interference.  Moleschatt's  Untersuchungen, 
1837,  vol.  i.,  p  84. 


40  PHYSIOLOGY  OF  THE  HEART 

originating  its  rhythmical  movements,  in  some- 
what the  same  way  as  the  brain  affects  the 
motor  cells  in  the  cord,  and  keeps  the  hand  still 
if  its  owner  wishes  to  do  so,  in  spite  of  irritation 
to  the  hand.  The  structures  through  which  the 
vagi  acted  they  regarded  as  inhibitory  ganglia 
in  the  heart  itself.  This  view  seems  to  receive 
confirmation  from  the  fact  that  when  Remak's 
ganglia  are  stimulated  the  auricles  and  ventricles 
stand  still  while  this  sinus  continues  to  pulsate. 

Inhibitory  Ganglia.  Stannius's  Experi- 
ments.— In  1852  Stannius30  showed  that  if  a 
ligature  is  tied  around  the  heart  exactly  at  the 
spot  where  the  venous  sinus  joins  the  auricles, 
or  if  the  heart  is  cut  across  at  this  point,  the 
auricles  and  ventricles  stand  still,  while  the 
sinus  and  vena  cava  continue  to  beat  as  before 
(Fig  11,0).  This  result  is  easily  explained  on 
the  myogenic  theory  by  the  supposition  that 
the  muscular  tissue  in  the  sinus  and  auricles 
is  the  source  of  the  stimuli  to  rhythmic  action, 
and  the  auricles  and  ventricle  stand  still  because 
the  ligature  prevents  these  stimuli  from  reach- 
ing them,  just  as  the  clamp  cut  off  the  ventricle 
in  Gaskell's  block  experiment. 

Another  experiment  is  not  so  easy  to  explain 
on  this  theory.  If  a  second  ligature  be  tied 
around  such  a  heart  exactly  at  the  groove 
between  the  auricles  and  ventricle  (Fig.  n,c), 
or  if  a  cut  be  made  here,  the  auricle  remains 
still  as  before,  but  the  ventricle  commences  to 
beat  again,  though  at  a  slower  rate  than  the 
sinus  (Fig.  n,  £). 

This  seems    to   necessitate    the   assumption 


41 

that  there  is  a  second  motor  centre,  either 
nervous  or  muscular,  in  the  ventricle  itself, 
whilst  the  auricles  do  not  possess  such  a 
centre,  and  therefore  stand  still. 


FIGS.  11  and  12. — AUTHOR'S  DIAGRAMS  TO  ILLUSTRATE  THE  EXPERIMENTS 
OF  STANNIUS. 

Fio.  11.— o,  Diagram  of  frog's  heart  ligatured  at  the  junction  of  the 
venous  sinus  with  the  auricles.  The  vense  cavse  and  sinus  are 
represented  with  a  crenated  outline  resembling  the  tracing  which 
their  beats  might  give  if  recorded  on  a  revolving  cylinder.  The 
auricle  and  ventricle  being  motionless  would  only  trace  a  straight  line 
if  connected  with  a  recording  apparatus.  Their  outline  is  therefore 
represented  by  a  straight  line,  b,  Diagram  of  a  frog's  heart  in  which 
sections  have  been  made  at  the  junction  of  the  sinus  with  the 
auricles,  and  at  the  auriculo-ventricular  groove.  The  sinus  and 
ventricles  pulsate,  whilst  the  auricles  remain  motionless.  The  beats 
of  the  ventricle  are  represented  as  slower  than  those  of  the  auricle. 
e,  The  same  as  b,  but  with  the  parts  of  the  heart  separated  by  ligature 
instead  of  section. 


d  e  f 

FIG.  12. — d,  Diagram  of  heart  with  ligature  round  the  venous  sinus. 
e,  Diagram  of  heart  with  ligature  round  middle  of  auricles.  /,  Diagram 
of  hpart  with  ligature  in  the  auriculo-ventricular  groove.  The  pulsa- 
tions of  the  ventricle  are  much  slower  than  those  of  the  auricle  and 
venous  sinus.  This  in  indicated  by  the  larger  dentation  of  the  outline 
of  the  ventricle. 

But  a  third  experiment  seems  to  show  that 
this  explanation  is  insufficient.  If  instead  of 
tying  a  ligature  at  the  junction  of  the  venous 
sinus  and  auricles  it  be  tied  round  the  auricles 


42  PHYSIOLOG  Y  OF  THE  HEART 

low  down,  near  their  junction  with  the  ventricle, 
the  sinus  and  upper  part  of  the  auricles  continue 
to  beat,  but  the  lower  part  of  the  auricle  and  the 
ventricle  after  one  or  two  pulsations  (Fig.  12,  e) 
stand  still.  This  appears  to  show  that  in  the 
lower  part  of  the  auricles  there  is  some  inhibitory 
apparatus  which  prevents  the  ventricle  from 
beating,  as  it  would  do  if  the  whole  of  the 
auricle  were  separated  from  it  either  by  liga- 
ture or  section.  The  portion  of  auricle  which 
prevents  the  ventricle  from  beating  may  be 
very  small.  I  have  seen  the  ventricle  of  a 
frog's  heart,  from  which  the  venous  sinus  and 
auricles  appeared  at  first  sight  to  have  been 
completely  cut  away,  obstinately  refuse  to  beat, 
until  a  fragment  of  auricle  about  the  size  of  a 
pin's  head,  which  had  at  first  been  overlooked, 
was  cut  away.  Then  the  ventricle  at  once 
began  to  pulsate  rhythmically.  The  pheno- 
menon was  like  a  big  horse  held  still  by  a  small 
jockey,  whose  removal  at  once  allowed  the 
horse  to  go  on.  It  is  very  difficult  to  explain 
this  on  the  ordinary  myogenic  theory,  but  easy 
if  we  suppose  some  of  the  ganglion  cells  in  the 
auricle  to  have  an  inhibitory  action. 

An  inhibitory  apparatus  of  some  kind  ap- 
pears to  be  present  in  the  venous  sinus  also, 
for  stimulation  of  this  part  of  the  heart  will 
produce  still  stand  of  the  whole  heart.31 

Refractory  Period  of  the  Heart. — Through- 
out nature,  whenever  an  action,  which  would 
otherwise  be  continuous,  meets  with  a  resistance 
it  tends  to  become  intermittent.  Thus  the  wind 
usually  blows  in  gusts,  each  of  which  is  followed 


REFRACTOR  Y  PERIOD  OF  HEART       43 


FIG.  13. 


FIG.  15. 


FIGS.  13, 14,  and  15. — Showing  the  effect  of  electrical  stimulation  of  the  frog'i 
heart.  The  upper  tracing  shows  the  beats  of  the  ventricle,  the  lower 
those  of  the  auricle,  and  the  depression  in  the  middle  line  shows  the 
time  of  applying  the  stimulus  by  breaking  the  current.  The  dotted 
line  shows  the  relation  of  this  to  the  contraction.  Fig.  13  shows 
stimulation  during  the  refractory  period  ;  Figs.  14  and  15,  after  this 
period  has  passed. 


44  PHYSIOLOG  Y  OF  THE  HEART 

by  a  lull,  and  the  flow  from  a  fountain  usually 
occurs  in  jets.  It  seems  as  if  time  were  required 
for  the  accumulation  of  energy  to  overcome  the 
obstacle,  and  when  this  is  done  the  energy 
spends  itself,  and  then  another  period  of  rest 
must  ensue  to  allow  of  a  fresh  accumulation. 
As  already  mentioned  (p.  5),  action  is  neces- 
sarily followed  by  sleep.  In  the  frog's  heart 
there  is  a  time  during  which  the  ventricle  does 
not  contract  in  response  to  stimulation,  either 
from  the  sinus  or  auricle,  or  directly  applied  to 
the  ventricle  itself.  This  was  discovered  by 
Kronecker,32  and  later  by  Marey,33  who  gave 
it  the  name  of  "  Refractory  Period."  Its  time 
relations  and  the  electrical  changes  which  ac- 
company it  were  investigated  by  Sir  John 
Burdon-Sanderson  and  Mr  Page.34 

Experiments  of  Brim  ton  and  Cash. — It  was 
also  experimented  on  by  Dr  Cash  and  myself, 
and  the  results  we  obtained  are  shown  in  the 
'accompanying  figures.35 

Refractory  Period  of  the  Ventricle. — From 
these  it  will  be  seen  that  during  the  greater 
part  of  its  systole  electrical  stimulation  of  the 
ventricle  itself  has  no  effect,  but  the  ventricle 
responds  to  the  stimulus  when  it  is  applied  just 
as  the  systole  is  ending  and  during  the  diastole. 

Refractory  Period  of  the  Auricle. — This  is  not 
so  well  marked  as  that  of  the  ventricle,  but  the 
tracing  in  Fig.  16  shows  that  stimulation  of  it 
during  its  diastole  may  cause  it  to  contract. 
This  induced  contraction,  instead  of  being 
followed  by  a  contraction  of  the  ventricle,  is 
succeeded  by  a  prolonged  pause,  and  when  the 


STIMULATION  OF  AURICLE  AND  SINUS  45 

stimulus  is  applied  at  the  height  of  its  contrac- 
tion only  a  prolonged  pause  is  produced  both  in 
auricles  and  ventricle. 


Fio.  16. — Shows  effect  of  stimulation  of  the  auricle  on  the  beats  of  the 
auricle  itself  and  of  the  ventricle. 

Stimulation  of  the  Venous  Sinus. — Stimula- 
tion of  the  venous  sinus  causes  reduplication  ol 
the  auricular  beat,  but  absence  of  the  ventricular 
beat  which  ought  to  have  followed  it ;  just  as  two 
trains  may  be  started  in  almost  immediate  suc- 
cession from  one  station,  but  the  second  may  be 
stopped  by  a  telegraphic  message  (Fig.  17). 


FIG.  17. — Shows  the  eflect  of  stimulation  of  the  venous  sinus. 

It  may  be  considered  that  this  effect  is  due  to 
extension  of  the  stimulus  to  the  auricle ;  but  I 
do  not  think  this  is  the  case  in  the  experiments 
made  by  Cash  and  myself,  because  the  tracing, 
Fig  17,  was  obtained  with  a  minimal  stimulus 


46  PHYSIOLOGY  OF  THE  HEART 

which  would  not  extend  to  the  auricle.  It  may 
be  said  that  the  reason  the  ventricular  beat 
did  not  follow  the  induced  auricular  beat  was 
because  the  stimulus  proceeding  from  the  auricle 
reached  the  ventricle  during  its  refractory  stage. 
But  a  comparison  of  Fig.  17  with  Figs.  14  and 
15  will  show  that  the  stimulus  from  the  second 
auricular  beat  must  have  reached  the  ventricle 
after  its  refractory  period  had  passed. 

Engelmann  found  that  stimulation  of  the 
sinus  may  cause  systole  of  the  ventricle  with 
absence  of  the  auricular  beat.36 

Extra  Systoles. — Except  during  the  refrac- 
tory period,  a  stimulus  applied  to  the  ventricle 
itself,  to  the  auricle,  or  to  the  venous  sinus  will 
produce  a  ventricular  contraction.  To  such  a 
contraction  occurring  out  of  the  usual  rhythm 
the  name  of  extra  systole  is  given.87  Extra 
systoles  have  been  classified  into  ventricular, 
auricular,  and  venous,  according  to  the  part 
from  which  the  stimulus  proceeds.38 

Compensatory  Pause. — An  extra  systole  is 
generally  followed  by  a  longer  pause  than 
normal,  so  that  its  occurrence  does  not  neces- 
sarily quicken  the  pulse,  and  two  systoles  close 
together  followed  by  a  long  diastole  generally 
occupy  the  same  time  as  two  normal  beats.  If 
the  extra  systole  is  induced  by  a  stimulus  at  the 
vena  cava  it  is  not  followed  by  a  compensatory 
pause.39 

Conduction  of  Stimuli  in  the  Heart  by 
Nerves  as  well  as  by  Muscle. — Engelmann's 
experiment,  in  which  he  showed  that  a  heart 
cut  into  zigzag  strips  so  as  to  divide  any  nerves 


PRACTICAL  BEARING  OF  EXPERIMENTS  47 

in  it,  would  transmit  a  contraction  caused  by  a 
stimulus  to  one  end  of  the  strip,40  shows  that 
the  cardiac  muscle  can  conduct  a  stimulus.  But 
the  experiments  of  Cash  and  myself,  which  were 
not  only  very  numerous,  but  very  varied,  show, 
we  think,  that  in  the  heart,  just  as  in  a  medusa, 
there  are  two  channels,  one  muscular  and  the 
other  nervous,  by  which  stimuli  are  conducted 
from  one  part  of  the  heart  to  another.  They 
seem  also  to  show  that  nervous  conduction  may 
interfere  with  muscular  conduction  (Fig.  17). 

Practical  Bearing  of  these  Experiments. — 
There  is  now  a  tendency  to  explain  intermittent 
pulse  by  the  supposition  that  it  is  caused  by 
some  kind  of  block  in  the  transmitting  structures, 
whilst  these  experiments  show  that  the  inter- 
missions may  occur  without  any  block  except 
that  caused  by  interference  of  stimuli  (vide  p.  36). 

The  practical  importance  of  the  myogenic  and 
neurogenic  theories  is  that  if  the  myogenic 
theory  be  true  to  the  exclusion  of  the  neurogenic, 
only  those  drugs  will  be  of  use  in  cardiac  disease 
which  act  on  the  cardiac  muscle,  and  such  drugs 
as  strychnine,  which  has  a  powerful  action  on 
nerves  but  little  or  none  on  muscle,  will  be  of 
little  or  no  use. 

LITERATURE. 

1  Lauder    Brunton,  Journ.  Anat.   and  Physiol.^    April 

1876,  vol.  x.,  p.  602  ;  Ranvier,  Leqons  cPAnatomie 
Gtnerale,  annte  1877-78  (Paris,  1880 :  J.  B.  Bailli&re 
et  Fils),  p.  42. 

2  Gaskell,  Phil.  Trans.,  1882,  p.  994. 

3  Remak, "  Neurologische  Erlauterungen,"  Mullens  Arch. 

f.  Anat,  u.  Physiol.,  1844,  p.  463. 


48  LITERATURE 

4  Bidder  and  Rosenberger,  Mutter's  Arch.  f.  Anat.  u. 
Physiol.,  1852,  p.  172  et  seq. 

•"'  Ludwig,  Arch.f.  Anat.  u.  Physiol.,  1848,  pp.  139-143. 

fi  S.  Tawara,  Das  Reizleitungssystem  des  Saugethier- 
herzens  (Fischer,  Jena,  1906),  p.  185. 

'  Purkinje,  "  Mikroscopisch  -  neurologische  Beobach- 
tungen,"  Mailer's  Archiv,  1845,  p.  281;  Ranvier, 
Leqons  <? Anatomic  Ge"n<*rale  sur  le  Systtme  Muscu- 
laire  (Paris  :  A.  Delahaye  &  Co.,  1880),  p.  325  et  seq. 

s  Tawara,  op.  cit.,  p.  185. 

9  Ranvier,  Lemons  cf  Anatomic  Ge"ne"rale  sur  le  Systime 

Musculaire,  1880,  p.  300. 

10  Hermann,  Handb.  der  Physiol.,  1879,  Bd.  i-,  Theil  i, 

p.  113  ;  Biedermann,  Silzungsb.  d.  k.  Akad.  d.  Wiss. 
math.-phys.  Cl.,  1880,  Bd.  Ixxxii.,  3  Abt.,  p.  257  et  seq.  ; 
Biedermann,  Electro-physiology,  trans.  F.  A.  Welby, 
1896  (London  :  Macmillan  &  Co.),  vol.  i.,  p.  105. 

11  Ranvier,  Lemons,  1877-8,  pp.  47  and  143. 

12  Bowditch,  Her.  d.  sacks.  Gesellsch.,  1871,  p.  682,  and 

Ludivig's  Arbeiten,  1871,  p.  176;  Merunowicz, 
Ludivigs  Arbeiten,  10*"  Jahrg.,  for  1875,  P-  '4O5 
and  Ber.  d.  sacks.  Gesellsch.,  1875,  P-  254  5  Eckhard, 
Beitrdge  z.  Anat.  u.  PhysioL,  1888,  p.  153  ;  Ranvier, 
Lemons,  1877-8,  pp.  47  and  143. 

13  Langendorff,  Arch.  f.  Anat.  u.  Physiol.,  Phys. 

1884,  Supp.  Bd.,  p.  8  etseq. 

14  Munk,    1 86 1,    Beilage    z.    Tagebl.    d.   Naturforscher 

Versaml.  zu  Speyer,  p.  46,  quoted  by  Tigerstedt, 
Lehrb.  d.  Physiol.  d.  Kreislaufes,  p.  198. 

15  Marchand,  P  finger's  Archiv,  1878,  vol.  xviii.,  p.  513. 

10  Goltz,  Archiv  f.  path.  Anatomic,  1861,  vol.  xxi.,  p.  201 
et  seq. 

17  For  a  full  discussion  of  this  question,  vide  Gaskell  on 

"  The  Contraction  of  the  Cardiac  Muscle,"  Schafer's 
Physiology,  vol.  ii.,  pp.  169-227  (Edin.  and  London  : 
Pentland,  1900). 

18  Gaskell,  Phil.  Trans.,  London,  1882,  vol.  clxxiii.,  pp. 

999  and  1031. 

19  Romanes,  Phil.  Trans.,  vol.  clxvi.  (1876),  p.  270. 

20  Romanes,  Phil,  Trans.,  vol.  clxxi.  (1880),  p.  163. 

21  Romanes,  Phil.  Trans.,  vol.  clxvii.  (1877),  p.  688  ;  Bow- 

ditch,  Ludwigs  Arbeiten,  1871,  p.  155. 


LITERATURE  OF  CHAPTER  11  49 

-  Romanes,  Phil.  Trans.,  vol.  clxxi.  (1880),  p.  191. 

23  Romanes,  Phil.  Trans.,  vol.  clxvi.  (1876),  p.  272. 

24  Romanes,  Phil.  Trans.,  vol.  clxvi.  (1876),  pp.  293  and 

294.    See  also  Romanes,  "Jelly  Fishes,  Star-fish,  and 
Sea-urchins,"  vol.  iv.  of  International  Scientific  Series 
(Kegan  Paul,  Trench  &  Co.,  London,  1885). 
26  Sir  John  F.  W.  Herschel,  Phil.  Magazine,  vol.  iii., 
1833,  p.  405. 

26  For  a  discussion  of  this  subject,  vide  Lauder  Brunton 

on  "  Inhibition  Peripheral  and  Central,"  West  Riding 
Asylum  Reports,  vol.  iv.,  1872  ;  and  "On  the  Nature 
of  Inhibition,  and  the  Action  of  Drugs  upon  it," 
Nature,  ist  March  1883,  vol.  xxvii.,  p.  419. 

27  Romanes, Phil.Trans., vol.  clxvii.  (1877),  PP-  718  and 729; 

Alfred  Goldsborough  Mayer,  "  The  Cause  of  Rhyth- 
mical Pulsation  in  Scyphomedusae,"  advance  print 
from  the  Proceedings  of  the  Seventh  International 
Zoological  Congress  (Boston,  1907  ;  Cambridge,  Mas- 
sachusetts, 1909),  p.  i.' 

28  A.  G.  Mayer,  op.  cit. 

29  Eduard  Weber,   Wagner's  Handworterb.  d.  Physiol., 

1846. 

30  Stannius,  Mailer's  Arch.f.  Ana/,  u.  Physiol.,  1852,  pp. 

85-92. 

31  A.   B.   Meyer,  Hemmungsnervensystem  des  Herzens, 

Berlin,  1869 ;  Schmiedeberg,  Ludwig's  Arbeiten, 
1870,  p.  44. 

32  Kronecker,  Beitrdge  z.  Anat.  u.  Physiol.  (C.  Ludwig, 

gewidmet,  1874),  p.  181. 
!3  Marey,  Travaux  du  Laboratoire,  2,  p  78  :  1876. 

34  Burdon-Sanderson  and  Page,  Journ.  of  Physiol.,  1880, 

vol.  ii.,  p.  384  ;  1884,  vol.  iv.,  p.  327. 

35  Brunton  and  Cash,  Roy.  Soc.  Proceed.,  1881,  vol.  xxxii., 

p.  383  ;  1883,  vol.  xxxv.,  p.  455. 
'  Engelmann,  Pfliiger's  Archiv,  1894,  vol.  Ivi.,  p.  149. 

37  Engelmann,  op.  cit. 

38  Hirschfelder,  Diseases  of  the  Heart  and  Aorta,  (London 

and  Philadelphia:  Lippincott,  1910),  p.  69. 

39  Martin  Flack,  Further  Advances  in  Physiology,  p.  52 

(London  :  Edward  Arnold,  1909). 

40  Engelmann,  op.  cit.,  1875,  vol.  xi.,  p.  466  et  seq. 


CHAPTER    III 

PHYSIOLOGY  OF  THE  MAMMALIAN  HEART 

Muscular  Structure  of  the  Mammalian  Heart — Nature 
of  the  Cardiac  Muscle — Intrinsic  Nerves  of  the 
Heart — Contraction  of  the  Mammalian  Heart — 
Active  Dilatation  of  the  Heart  —  Characteristics 
of  the  Heart— Origin  of  Stimuli  in  the  Mam- 
malian Heart  —  Nodes — Position  of  the  Nodes — 
Structure  of  the  Nodes — Connections  of  the  Nodes 
— Bundle  of  Stanley  Kent  and  His  —  Pacemaker  of 
the  Heart — Nodal  Rhythm — Heart-block  —  Cause 
of  Heart-block  in  Man — Functional  Heart-block — 
Noeud  Vital  of  the  Heart — Kronecker  and  Schmey's 
Experiments — Fibrillation — Extrinsic  Nerves  of  the 
Heart — Functions  of  these  Nerves — Complex  Func- 
tions of  the  Vagus — Afferent  and  Sensory  Nerves  of 
the  Heart  —  Pain  —  Depressor  Nerve  —  Mode  of 
Action  of  the  Vagus  on  the  Heart — Opposite  Effects 
of  the  Vagus  on  Heart-block — Trophic  Action  of 
the  Vagus — Accelerator  Nerves  of  the  Heart — 
Reflex  Stimulation  of  the  Cardiac  Nerves— Reflex 
Stimulation  of  Inhibition — Valves  of  the  Heart — 
Sounds  of  the  Heart — Double  Nature  of  the  Heart — 
Right  Ventricle. 

Muscular  Structure  of  the  Mammalian 
Heart. — By  using  Purkinje's  method1  of  boiling 
a  calf's  heart  for  half  an  hour  in  vinegar,  it  is 
easy  to  ascertain  that  the  ventricles  are  com- 
posed of  muscular  fibres  which  run  more  or  less 

60 


MUSCLE  OF  MAMMALIAN  HEART       51 

longitudinally  on  the  inside  and  outside,  and 
transversely  in   the   middle  of  the  ventricular 


Fio.  18. — Cells  taken  from  a  heart  in  fibrillation.  The  preparation 
shows  that  the  intercellular  limits  separate  very  sharply  parts  with 
stri«  widely  apart  from  otheis  with  striae  close  together,  whilst  in 
the  interior  of  the  cells  numerous  transitions  may  be  observed.  The 
larger  figure  (a)  is  magnified  750  diameters  by  an  appchromatic 
objective,  No.  2  of  Zeiss,  and  compensating  eyepiece,  No.  6.  The 
small  portion  (fe)  strongly  magnified  was  observed  with  Zeiss's  No.  2 
objective  and  a  compensating  eyepiece,  No.  18,  with  an  intense 
illumination.  Its  position  in  a  is  marked  by  the  rectangle  of  dotted 
lines.  (After  Kronecker  and  Imchauetzky.) 

wall.     These   are  connected   by  oblique  fibres, 
and  some  of  them  end  in  the  musculi  papillares, 


52    PHYS1OLOG  Y  OF  MAMMALIAN  HEART 

The  course  of  these  fibres  has  been  ascertained 
much  more  exactly  by  C.  Ludwig  and  others.* 

Nature  of  the  Cardiac  Muscle. — The  cardiac 
muscle  is  unlike  any  other  muscle  in  the  body, 
either  voluntary  or  involuntary.  Its  fibres  are 
not  composed  of  spindle-shaped  cells,  but  of 
more  or  less  quadrangular  cells  which  are  some- 
times joined,  end  to  end.  They  have  a  tendency 
to  divide  at  the  end,  and  the  divisions  anasto- 
mose with  those  from  other  fibres,  thus  producing 
a  kind  of  network  (Fig.  18).  It  was  formerly 
supposed  that  they  were  connected  with  one 
another  by  some  cement  substance,  because 
under  the  microscope  divisions  between  them 
appeared  quite  definite.  Of  late  years  there 
has  been  a  tendency  to  suppose  that  they  really 
form  a  syncytium  or  united  cell,  through  all 
parts  of  which  stimuli  can  be  propagated  in  any 
direction.2  This  view,  however,  cannot  be 
accepted  without  limitation,  because  in  fibrilla- 
tion a  single  cell  may  be  found  contracted  while 
the  adjacent  cells  are  relaxed3  (Fig.  18). 

Intrinsic  Nerves  of  the  Heart. — The  nerves 
of  the  heart  may  be  regarded  as  consisting  of 
two  kinds.  First,  neuro-muscular,  forming 
nodes  and  fibres ; 4  second,  ordinary  ganglia 
and  nerve  fibres.  These  are  very  numerous,5 
and  though  opinions  may  be  divided  in  regard 
to  the  part  they  take  in  originating  the  cardiac 
contractions  or  conveying  stimuli  from  one  part 
of  the  heart  to  another,  physiologists  are 

*  C.  Ludwig,  Lehrbuch  der  Physiologie  (Us  Menschen, 
vol.  ii.,  p.  78  el  seq,  (Leipzig  and  Heidelberg :  Winter, 
1858) ;  also  Quain's  and  other  textbooks  of  anatomy. 


INTRINSIC  SENSOR  Y  NER  VES  5  3 

generally  agreed  that  they  serve  to  co-ordinate 
the  action  of  the  heart  with  that  of  the  vessels. 

So  numerous  are  the  nerves  of  the  heart,  that 
Dr  Robert  Lee  says,6  "It  can  be  clearly 
demonstrated  that  every  artery  distributed 
throughout  the  walls  of  the  uterus  and  heart, 
and  every  muscular  fasciculus  of  these  organs, 
is  supplied  with  nerves  upon  which  ganglia  are. 
formed."  This  statement  made  by  Lee  in  1849, 
has  been  to  a  great  extent  confirmed  by  Retzius,7 
who  limits  it,  however,  by  saying  that  it  is  hardly 
possible  that  every  muscular  fibre  receives  a 
nerve,  and  that  in  fact  many  fibres  may  be  seen 
which  are  not  in  contact  with  nerve  endings. 
Retzius,  Ramon  y  Cajal,8  and  H.  J.  Berkeley9  all 
agree  that  the  nerve  terminations  form  a  net- 
work round  the  muscular  fibres,  and  that  upon 
them  varicosities  may  be  observed.  These  are 
regarded  by  Berkeley  as  bipolar  nerve  cells. 
Heymans  and  Demoor 10  have  again  investigated 
the  whole  question,  and  while  they  find  bodies 
which  greatly  resemble  ganglionic  cells  lying 
between  the  muscular  fibres,  they  are  inclined 
to  consider  them  as  connective  protoplasmic 
cells.  They  agree,  however,  with  the  others  in 
regard  to  the  existence  of  a  fine  network  of 
nerve  fibrils  surrounding  the  muscular  fibres. 
This  network,  as  figured  by  them  in  Fig.  34, 
Plate  xviii.,  and  others  of  their  work,  is  almost 
exactly  like  that  upon  arteries  (Fig.  25,  p.  85). 

Intrinsic  Sensory  Nerves. — It  would  appear 
from  some  experiments  of  von  Basch  and  A. 
Frohlich11  that  some  of  the  nerves  in  the  heart 
are  sensory,  and  give  rise  when  stimulated  to 


5 4    Pff YS10LOG  Y  OF  MAMMALIAN  HEART 

extra  systoles ;  for  when  a  limited  part  of  the 
epicardium  is  carefully  painted  with  a  solution 
of  cocaine,  an  electrical  stimulus  applied  to 
that  part  requires  to  be  greatly  increased  in 
order  to  produce  an  extra  systole,  while  the 


Pio.  19. — Anterior  cardiac  plexus  of  nerves.  (After  Robert  Lee.)  a, 
Origin  of  pulmonary  artery  which  has  been  completely  removed ;  b, 
anterior  surface  of  the  right  ventricle ;  c,  anterior  surface  of  the  left 
ventricle ;  d,  left  vagus  ;  e,  the  trunk  of  the  left  coronary  artery  ossified 
and  completely  surrounded  with  ganglia  and  nerves,  which  are  dis- 
tributed over  the  whole  surface  of  the  ventricle  to  the  apex. 

other  parts  of  the  heart  retain  their  normal 
sensitiveness  ;  and  other  experiments  show  that 
this  diminution  in  sensibility  is  not  due  to  any 
alteration  in  the  muscle  underlying  the  epi- 
cardium. 


MOVEMENTS  OF  HEART  55 

Contraction  of  the  Mammalian  Heart. — In 
mammals,  as  I  have  already  mentioned  (p.  21), 
the  vena  cava  and  pulmonary  veins  may 
continue  to  beat  rhythmically  after  the  rest 
of  the  heart  has  ceased  to  beat,  but  usually  the 
contraction  of  the  heart  begins  in  the  auricles 
at  their  junction  with  the  veins,  and  passes  on 
to  the  ventricles.  Electrocardiograms  seem  to 
show  that  the  ventricle  begins  first  to  contract 
slightly  at  the  base,  next  the  apex  contracts,  and 
then  the  base  again  forcibly.12  This  arrange- 
ment is  well  adapted  to  drive  the  blood  com- 
pletely out  of  the  heart,  for  the  slight  contraction 
at  the  base  will  contract  the  auriculo-ventricular 
rings  and  prevent  regurgitation,  the  simultaneous 
contraction  of  the  musculi  papillares  and  of  the 
apex  will  have  the  double  effect  of  keeping  the 
valves  tight  and  driving  the  blood  on  into  the 
vessels,  while  the  final  contraction  at  the  base 
will  finish  the  expulsion  of  the  ventricular 
contents. 

Active  Dilatation  of  the  Heart. — This  is 
greatly  disputed,  but  there  seems  some  evi- 
dence to  show  that  under  the  influence  of 
vagus  stimulation  a  slight  actual  dilatation 
occurs.13 

Characteristics  of  the  Heart. — The  ventri- 
cular beat  is  a  single  muscular  contraction,  and 
not  a  tetanus.14  Very  strong  electric  currents 
applied  to  any  part  of  the  heart  will  paralyse 
the  cardiac  nerves  and  cause  fibrillation  (p.  63) 
of  the  muscle,  but  do  not  cause  tetanus.  Fre- 
quent electrical  stimuli  of  moderate  strength, 
such  as  would  cause  tetanus  in  a  voluntary 


56    PHYS1OLOG  Y  OF  MAMMALIAN  HEART 

muscle,  accelerate  the  beats  of  the  heart  Stimu- 
lation of  the  heart  causes  it  to  beat  either  with  its 
full  strength  or  not  at  all.  This  observation  was 
made  by  Bowditch,  and  formulated  by  Ranvier  in 
the  expression,  "All  or  none,"  an  expression 
which  has  since  been  called  "  Bowditch's  law."16 
The  activity  of  the  ventricle  has  been  described 
by  Gaskell  as  depending  on  five  factors: — ist, 
Rhythm  of  the  stimuli  (chronotrope) ;  2nd, 
rapidity  of  their  conduction  in  the  heart 
(dromotrope) ;  $rdt  excitability  to  stimuli 
(bathmotrope) ;  4///,  contraction  force  (ino- 
trope) ;  ^tht  tonicity.16  To  these  functions 
the  names  which  are  enclosed  in  brackets 
were  given  by  Engelmann,17  and  the  increase 
or  diminution  in  them  are  indicated  by  the 
terms  positive  and  negative.  Thus,  if  irritation 
of  the  vagus  slowed  the  heart  by  lessening  the 
production  of  stimuli  in  the  heart,  it  would  be 
said  to  exercise  a  negative  chronotrope  effect ; 
if  it  slowed  their  conduction  from  auricle  to  ven- 
tricle, it  would  exercise  a  negative  dromotrope 
effect ;  and  if  it  lessened  the  strength  of  the  ven- 
tricular contraction,  a  negative  inotrope  action. 

Origin  of  Stimuli  in  the  Mammalian  Heart. 
Nodes. — The  stimuli  to  contraction  are  sup- 
posed to  arise  from  two  nodes,  which  consist 
of  imperfectly  differentiated  muscle  or  neuro- 
muscular  tissue.18  It  is  to  be  remembered, 
however,  that  at  these  places  where  these  nodes 
occur  numerous  ganglion  cells  are  also  present 
and  are  often  arranged  in  groups  corresponding 
to  Remak's,  Ludwig's,  and  Bidder's  ganglia  in 
the  frog's  heart.19 


NODES  AND  A-V  BUNDLE  57 

The  first  of  these  is  known  as  Keith  and 
Flack's,  or  sino-auricular,  or  S-A  node.  It  is 
situated  in  the  right  auricle,  between  the  mouths 
of  the  venae  cavae.20  This  part  of  the  auricle 
is  sometimes  called  the  auricular  canal,  and 
corresponds  to  the  venous  sinus  in  the  frog. 
A  second  and  similar  node,  called  the  auriculo- 
ventricular  or  A-V  node,  is  situated  in  the  pos- 
terior part  of  the  right  auricle,  near  the  septum 
below,  and  to  the  right  of,  the  coronary  sinus.21 

Structure  of  the  Nodes. — They  both  consist 
of  a  complicated  network  of  peculiar  muscular 
fibre,  in  which  transverse  striation  is  very  in- 
distinct. They  have  few  fibrillae  and  much 
protoplasm.22 

Connections  of  the  Nodes. — These  two  nodes 
are  connected  by  muscular  fibre  in  the  auricular 
septum.23 

Bundle  of  Stanley  Kent  and  His. — From 
the  A-V  node  a  bundle  of  partially  differenti- 
ated fibres  is  given  off,  which  has  been  described 
by  Stanley  Kent24  and  His,  junior,25  and  care- 
fully examined  by  Tawara.26  It  is  generally 
known  shortly  as  the  bundle  of  His.  It  passes 
forwards  on  the  intra-ventricular  septum,  and 
then  divides  into  two  branches  which  run  for- 
wards towards  the  apex  of  each  side  of  the 
septum,  and  break  into  fibres  which  end  in  the 
musculi  papillares,  and  appear  to  be  identical 
with  the  fibres  first  described  by  Purkinje,  and 
known  by  his  name.  These  fibres  are  only 
striated  on  their  periphery,  and  may  be  re- 
garded as  neuro-muscular,  possessing  the  pro- 
perties both  of  muscle  and  nerve  (Fig.  20). 

F 


58    PH  YSIOLOG  V  OF  MAMMALIAN  HEART 

Pacemaker  of  the  Heart. — The  S-A  node  is 
supposed  to  be  more  sensitive  than  the  A-V 
node,  and  usually  to  act  as  the  pacemaker  of 
the  heart.27 

Nodal  Rhythm. — When  the  S-A  node  fails  to 
act  the  A-V  node  is  capable  of  initiating  a 
rhythm  of  its  own,  just  as  the  upper  part  of  the 
frog's  ventricle  does  when  entirely  separated 


FIG.  20. — Porkinje's  fibres  from  a  sheep's  heart,  n,  Nuclei;  c,  proto- 
plasm ;  /,  striated  muscular  substance.  (After  Ranvier,  Lcftms 
d'Anatomie  Gfniraiesur  le  Systime  Musculaire (Paris :  Delahaye  &  Co., 
1880),  p.  800.) 

from  the  auricle  (p.  30).  This  has  been  called 
by  Mackenzie,  Nodal  Rhythm.28 

Ventricular  contractions  due  to  stimuli  arising 
from  the  usual  place,  viz.  the  S-A  node,  have 
been  termed  nomotopic,  and  those  arising  from 
other  places  ectopic.29 

Heart-block. — The  same  phenomena  that 
Gaskell  observed  (p.  32)  when  the  auriculo- 
ventricular  groove  in  the  frog's  heart  was  com- 
pressed by  a  clamp  have  been  found  to  occur 


HEART-BLOCK  59 

also  in  the  mammalian  heart  when  the  conduc- 
tion between  the  auricle  and  ventricle  has  been 
lessened  or  destroyed  by  a  ligature  (Wool- 
dridge  30),  by  cutting  (Tigerstedt31),  or  by  crush- 
ing (MacWilliam  32),  or  by  clamping  the  bundle  of 
His  (Erlanger  33). 

Erlanger  has  found  that  when  the  bundle  of 
His  is  completely  compressed  by  a  clamp  the 
ventricle  may  only  respond  by  i  beat  to  2,  and 
when  the  clamp  is  tightened,  to  3  of  the 
auricles. 

When  the  clamp  is  still  farther  tightened,  the 
3 : 1  rhythm  is  succeeded  by  complete  heart- 
block,  so  that  the  beats  of  the  ventricles  become 
completely  independent  of  those  of  the  auricles 
and  usually  are  much  slower  than  they.  As 
only  the  bundle  of  His  is  compressed  in  this 
experiment,  the  blood  continues  to  be  driven 
into  the  ventricles  by  the  auricles.  They  thus 
become  distended,  and  after  two  or  three  waves 
of  blood  have  been  driven  in  they  contract,  but 
this  contraction  bears  no  constant  time-relation 
to  the  contractions  of  the  auricles,  so  that  the 
rhythms  of  the  auricles  and  ventricles  are 
separate  and  independent.  The  ventricular 
rhythm  is  usually  considerably  slower  than  the 
auricular,  which  is  on  an  average  3-05  times  as 
quick. 

When  the  bundle  of  His  is  incompletely 
compressed,  from  either  imperfect  application 
of  the  clamp  or  some  other  reason,  the  results 
are  somewhat  different  The  first  result  of 
tightening  the  clamp  may  be  the  lengthening 
of  the  interval  between  the  commencement  of 


60    PHYSIOLOG  Y  OF  MAMMALIAN  HEART 

the  auricular  systole  and  ventricular  systole. 
For  the  sake  of  brevity  the  auricular  systole  is 
often  denoted  by  the  letters  AS,  and  the  ven- 
tricular by  VS.  This  first  result  would  thus  be 
expressed  shortly  as  a  lengthening  of  the 
AS  VS,  or  still  more  shortly,  the  AV  interval. 
This  interval  may  gradually  increase  until  the 
ventricles  fail  to  respond  to  one  of  the  auricular 
contractions,  or,  in  other  words,  an  intermission 
occurs.  Immediately  after  this  the  AV  interval 
becomes  short  and  then  increases,  at  first  slowly 
and  then  quickly  until  the  next  intermission.  At 
first  the  intermissions  occur  irregularly,  and 
with  fairly  long  intervals,  the  longest  being 
27  beats,  but  as  the  compression  increases  the 
intermissions  begin  to  occur  regularly,  the  ven- 
tricle only  responding  to  2,  3,  4,  5,  6,  7,  8,  9,  or 
10  beats  of  the  auricles. 

Cause  of  Heart-block  in  Man. —  It  appears 
to  be  certain  from  numerous  observations  that 
the  bundle  of  His  does  not  consist  entirely  of 
undifferentiated  muscle  fibre,  but  contains 
numerous  nerve  fibres,  and  it  is  probable  that 
communication  may  be  maintained  between  the 
auricle  and  ventricle  in  certain  cases  by  nerve 
fibres  which  are  not  contained  in  this  bundle 
(Kronecker).  At  the  same  time,  so  many  cases 
have  been  recorded  where  fatty  degeneration  of 
this  bundle  has  been  found  on  post-mortem 
examinations  of  patients  who  have  suffered 
from  heart-block,  that  there  is  evidently  a  close 
connection  between  this  condition  and  the 
symptom.34 

Functional   Heart-block. — When  the  trunks 


KRONECKERS  EXPERIMENTS  61 

of  the  vagi  are  stimulated  by  a  faradic  current 
or  the  vagus  centre  in  the  medulla  by  digitalis, 
the  cardiac  pulsations  become  slower  or  stop 
altogether.  These  effects  are  due,  in  part  at 
least,  to  heart-block  (p.  68).  They  cease  when  the 
stimulus  to  the  vagus  trunk  is  discontinued,  or 
in  the  case  of  slowing  by  digitalis,  when  the  vagi 
are  cut,  so  that  the  inhibitory  stimulus  can  no 
longer  pass  from  the  medulla  to  the  heart 

Heart-block  in  such  cases  is  difficult  to  explain 
except  on  the  hypothesis  of  interference  (p.  36). 

Noeud  Vital  of  the  Heart.  Experiments  of 
Kronecker  and  Schmey. — Many  years  ago 
Flourens  showed  that  if  the  medulla  oblongata 
is  pricked  by  a  needle  just  at  the  lower  end  of 
the  calamus  scriptorius,  respiration  ceases  at 
once.35  To  this  point  he  gave  the  name  of 
nceud  vital  (Fig.  2l).  A  similar  point  appears 
to  exist  in  the  heart,  for  Kronecker  and  Schmey  36 
found  that  by  puncturing  a  point  in  the  septum 
between  the  ventricles,  about  the  junction  of  its 
upper  third  with  its  lower  two-thirds,  the 
rhythmical  action  of  the  heart  is  stopped  im- 
mediately, and  as  a  whole  it  is  quiescent,  though 
little  quivering  tremors  can  be  seen  all  over  the 
ventricle. 

In  both  cases  the  action  which  is  abolished  is 
an  alternating  one.  In  respiration,  it  is  that  of 
inspiration  and  expiration ;  in  the  heart,  that  of 
systole  and  diastole.  In  both  cases  the  arrest 
does  not  seem  to  be  due  so  much  to  paralysis 
as  to  disturbance  of  co-ordination  between  these 
alternating  movements.  Another  resemblance 
between  the  nceud  vital  of  the  respiration  and  that 


62    PHYS10LOG  Y  OF  MAMMALIAN  HEART 

of  the  heart  is  that  in  neither  case  does  the  effect 
seem  to  be  due  to  injury  of  ganglia.  The  nceud 
vital  was  investigated  by  Gierke,37  who  found 
that  it  practically  consisted  of  a  bundle  of  nerves 
connecting  the  two  sides  of  the  medulla  and  pass- 
ing to  the  nuclei  of  the  vagus  and  laryngeal 
nerves,  as  well  as  into  the  spinal  cord.  The 
existence  of  a  definite  centre  in  Kronecker's 


Fio.  21. — Noend  vital.  The  figure  shows  the  posterior  part  of  the  cerebral 
hemispheres,  cerebellum,  and  medulla  oblongata  in  the  rabbit.  The 
small  circle  8  indicates  the  position  and  size  of  the  nosud  vital.  (After 
Flourens,  Compt.  rendut,  1858,  voL  xlvii.,  p.  806,  fig.  8.) 

sense  has  been  denied,38  but  there  are  numerous 
nerve  fibres  along  the  septum. 

Fibrillation. — Fibrillary  tremors  are  due  to 
contraction  of  individual  muscle  cells  (Fig.  18, 
p.  51).  Though  a  very  large  number  of  cells 
may  be  contracting  at  the  same  time,  yet  as  all 
do  not  contract  co-ordinately,  the  ventricle  or 
auricle  as  a  whole  does  not  contract.  Fibrilla- 
tion of  the  ventricle  may  be  produced  by:39  (i) 


FIBRILLATION  63 

puncture  of  the  septum  as  above  mentioned ; 
(2)  ligature  of  the  coronary  arteries ;  (3)  embol- 
ism of  the  small  branches  of  the  coronary 
artery  ;  (4)  stimulation  by  powerful  interrupted 
electrical  currents  ;  (5)  by  rapid  cooling  to  25° ; 
(6)  sometimes  by  rapid  application  of  chloro- 
form. The  hearts  of  rabbits  may  sometimes 
recover  spontaneously ;  those  of  dogs  (unless 
very  young)  do  not.  They  may  sometimes  be 
restored  by  very  strong  electric  shocks  of  240 
volts  directly  to  the  heart. 

Consequences  of  Fibrillation. — Fibrillation 
of  the  ventricle  is  fatal  in  a  few  minutes,  but 
fibrillation  of  the  auricle  may  continue  for  weeks 
or  years  without  having  any  other  effect  than 
producing  great  irregularity  of  the  pulse,  and 
thus  impairing  the  circulation.40  When  camphor 
is  added  to  normal  saline  and  blood,  the  mixture 
removes  fibrillation  when  circulated  through  a 
heart.41 

Extrinsic  Nerves  of  the  Heart. — The  rela- 
tionships between  the  heart  and  the  body  which 
it  requires  to  supply  with  blood  in  all  its  parts 
and  under  varying  conditions  are  so  complicated 
that  one  would  expect  to  find  very  numerous 
nerves  connecting  the  body  and  the  heart ;  and 
this  is  indeed  the  case.  Around  the  base  of  the 
heart  itself  there  is  a  large  network  or  plexus  of 
nerves,  which  for  convenience  of  description  may 
be  divided  into  three  parts :  ( I )  superficial  plexus ; 
(2)  right  and  (3)  left  divisions  of  the  deep  or 
posterior  plexus.  To  these  may  be  added  the 
plexuses  which  accompany  the  anterior  and 
posterior  coronary  arteries  (Fig.  19,  p.  54). 


64     PH  YS10LOG  Y  OF  MAMMALIAN  HEART 

Nerves  pass  to  this  network  from  the  three 
great  cervical  ganglia,  and  from  the  vagus  nerve 
on  each  side.  The  connections  of  these  nerves 
with  one  another  and  with  the  spinal  cord  are 
very  complex,  and  need  not  be  described  here.42 

Functions  of  these  Nerves.  —  Speaking 
generally,  the  function  of  the  sympathetic 
nerves  is  to  quicken  and  strengthen  the  heart- 
beats, and  they  are,  therefore,  termed  accelerat- 
ing nerves. 

The  function  of  the  vagus,  generally  speaking, 
is  to  slow  the  cardiac  beats  and  render  them 
weaker  (inhibitory  action). 

Complex  Functions  of  the  Vagus. — This 
nerve  has  received  the  name  of  vagus  or 
wandering  nerve  (in  German — Herumschwei- 
fender  Nerv),  because  it  wanders  to  so  many 
organs  in  its  course ;  and  it  has  also  received  the 
name  of  pneumogastric,  because  it  sends  a  large 
nervous  supply  to  the  lungs  and  stomach  as  well 
as  the  intestines,  liver,  and  kidneys.  It  contains 
three  kinds  of  nerves:  (i)  medullated,  v/ith  a 
thick  medullary  sheath ; 43  (2)  medullated,  with 
a  thin  medullary  sheath;44  (3)  non-medullated 
nerves.43  Those  of  the  first  class  are  probably 
efferent  (motor  and  inhibitory),  those  of  the 
second  are  probably  afferent44  (sensory),  and 
those  of  the  third  are  sympathetic  (accelerating). 

Afferent  and  Sensory  Nerves  of  the  Heart. 
Pain.  —  The  probable  existence  of  intrinsic 
afferent  nerves  in  the  epicardium  has  already 
been  mentioned.  Afferent  nerves,  irritation  of 
which  will  cause  extra  systoles  followed  by  com- 
pensatory pauses,  appear  to  be  present  also  in 


SENSOR  Y  NER  VES  OF  HEART  65 

the  pericardium,  for  Heitler,45  under  von  Basch's 
direction,  found  that  stimulation,  either  mechani- 
cal or  electrical,  of  the  pericardium  produced 
extra  systoles  of  the  heart  in  dogs ;  but  when 
the  pericardium  was  painted  with  a  10  per  cent, 
solution  of  cocaine,  stimulation  ceased  to  produce 
any  result.  The  extrinsic  afferent  nerves  may 
cause  slowing  or  quickening  of  the  pulse,  and 
either  a  rise  or  fall  of  the  blood-pressure.  They 
produce  alterations  in  the  respiration,  and  may 
cause  general  reflexes  of  the  limbs,  a  fact  which 
indicates  that  they  can  produce  sensation  and 
probably  pain.46 

Depressor  Nerve. — In  rabbits  a  nerve  was 
found  by  Ludwig  and  Cyon47  which  originates 
in  fibres  in  the  ventricle,  passes  upwards,  and 
sends  one  branch  to  the  vagus,  and  another  to 
the  superior  laryngeal  nerve.  Stimulation  of  its 
peripheral  end  has  no  effect,  but  if  the  central  end 
of  the  cut  nerve  be  stimulated  the  blood-vessels 
of  the  intestines  dilate,  and  the  blood-pressure 
falls.  It  is  sometimes  present  as  a  separate 
nerve  in  man,  but  appears  sometimes  to  be 
amalgamated  with  the  vagus.48  It  is  not  always 
in  action,  but  if  the  pressure  within  the  heart,49 
or  perhaps  rather  in  the  aorta,50  rises  too  high 
it  comes  into  action,  lowers  the  pressure,  and 
eases  the  heart. 

Mode  of  Action  of  the  Vagus  on  the  Heart. — 
When  one  vagus,  especially  the  right,  is  stimu- 
lated, both  auricles  and  ventricles  beat  more 
slowly  and  more  feebly.  If  the  stimulus  is 
strong,  they  stand  quite  still  in  diastole  for 
4  variable  period,  after  which  they  begin  to 


66    PHYSIO  LOG  Y  OF  MAMMALIAN  HEART 

beat  again,  even  though  the  stimulation  be 
continued.  In  most  animals  the  auricle  re- 
sponds more  readily  to  vagus  stimulation  than 
the  ventricle,  and  may  stand  completely  still 
while  the  ventricle  continues  to  pulsate.51  On 
the  other  hand,  the  contractions  of  the  ventricle 
sometimes  almost  disappear,  while  the  auricles 
beat  more  strongly.  When  the  auricle  is  in  a 
state  of  fibrillation  stimulation  of  the  vagus  may 
sometimes  have  no  effect  on  the  auricle,  but  may 
slow  the  ventricle  or  stop  it  altogether.52  The 
exact  way  in  which  the  vagus  produces  these 
extraordinary  effects  has  given  rise  to  much 
experiment,  great  discussion,  and  is  not  yet 
positively  ascertained. 

Some  experiments  appear  to  show  that  the 
vagus  acts  on  the  cardiac  muscle  directly,  as  a 
motor  nerve  does  on  voluntary  muscle.  Others 
indicate  that  it  acts  indirectly  through  some 
kind  of  nervous  structures,  and  it  is  almost 
impossible  to  form  any  kind  of  complete  con- 
ception of  its  mode  of  action  unless  we  assume 
that  it  acts  both  on  muscle  and  nerve.  That  it 
acts  on  muscle,  appears  to  be  indicated  by  the 
fact  that  it  causes  inhibition  in  the  hearts  of 
invertebrates  in  which  no  ganglion  cells  have 
been  found,  and  also  in  strips  cut  from  parts 
of  a  vertebrate  heart  supplied  by  the  vagus,  but 
containing  no  ganglion  cells.53 

That  it  acts  on  nervous  structures  as  well,  is 
indicated  by  the  fact  that  it  does  not  act  at 
once  upon  the  heart  as  a  motor  nerve  does  on 
a  muscle,  but  there  is  a  somewhat  long  latent 
period,51  amounting  often  to  as  much  as  the 


INHIBITORY  ACTION  OF  VAGUS          67 

time  of  one  or  even  two  pulse-beats  before 
stimulation  produces  an  effect,  and  continues 
to  act  for  a  considerable  time  after  the  stimula- 
tion has  ceased  (Fig.  91,  p.  300).  Moreover,  the 
effects  of  drugs  on  the  vagus  are  very  difficult  or 
impossible  to  explain  on  the  theory  that  it  acts 
only  on  the  heart  muscle.55 

The  inhibitory  fibres  were  shown  by  A.  Waller 
to  be  really  derived  from  the  spinal  accessory 
nerve,  because  when  the  roots  of  this  nerve  are 
torn  at  the  jugular  foramen  so  that  it  is  de- 
stroyed, and  its  fibres  degenerate,  the  inhibitory 
function  of  the  vagus  is  lost,  and  stimulation  of 
its  trunk  no  longer  slows  the  heart.56  The  deep 
origin  of  this  nerve  is  the  inhibitory  centre  for  the 
heart,  and  is  situated  in  the  medulla  oblongata.57 
In  some  tortoises  only  the  right  vagus  has  any  in- 
hibitory power ;  ^  and  I  have  frequently  noticed 
in  rabbits  that  the  inhibitory  power  of  the  right 
vagus  is  much  stronger  than  that  of  the  left. 
Branches  of  the  right  vagus  go  chiefly  to  the 
deep,  and  those  from  the  left  to  the  superficial 
cardiac  plexus. 

The  inhibitory  fibres  of  the  vagus  may  (i)  slow 
the  beats  of  the  heart  without  altering  their 
strength,  or  (2)  may  weaken  them  without 
altering  their  rate,  or  (3)  may  both  slow  them 
and  weaken  them.59  On  account  of  sym- 
pathetic fibres  being  contained  in  the  vagus 
trunks,  stimulation  of  them  may  occasionally 
cause  quickening  and  strengthening  of  the 
heart's  beat  instead  of  the  usual  effect.60  Other 
motor  fibres  go  to  abdominal  organs,61  and 
probably  some  go  to  the  lungs.6'2  According  to 


68    PHYSIOLOGY  OF  MAMMALIAN  HEART 

Gaskell,  the  vagus  may  slow  or  stop  the  heart 
by  depressing  (i)  its  power  of  originating 
rhythmical  stimuli ;  (2)  of  conducting  them 
(block) ;  (3)  of  responding  to  them  (less  excit- 
ability); (4)  its  contraction  force;  (5)  its 
tonicity.63 

Some  recent  investigations  by  A.  E.  Cohn64 
may  help  to  explain  why  such  differing  results 
have  been  obtained  by  stimulation  of  the  vagi. 
Although  Gaskell  and  others  have  observed 
differences  in  the  nature  as  well  as  in  the 
amount  of  action  exerted  in  the  heart  by  stimu- 
lation of  the  right  and  left  vagus,  yet  the  differ- 
ences in  nature  have  not  been  explained.  From 
a  consideration  of  the  results  obtained  by 
previous  observers  as  well  as  from  his  own 
experiments,  Cohn  comes  to  the  conclusion  that 
both  nerves  have  the  double  power  of  depressing 
the  origination  of  stimuli  in  the  heart  and  of 
lessening  their  conduction.  The  power  of 
depressing  stimuli  is  greater  in  the  right 
vagus,  whilst  that  of  lessening  conduction  is 
greater  in  the  left.  Cohn  illustrates  his  idea 
by  a  diagram  (Fig.  22)  which  does  not  com- 
pletely explain  all  the  results,  and  is,  therefore, 
imperfect,  but  at  the  same  time  it  helps  to  link 
the  facts  together. 

It  is  clear  that  the  vagus  owes  its  power  of 
slowing  or  stopping  the  ventricle  in  part  to 
its  producing  heart-block,64  and  preventing  the 
stimuli  from  the  auricle  from  passing  as  usual 
to  the  ventricle.  Gaskell  states  that  he  has 
never  seen  any  evidence  that  an  excitation-wave 
(p.  32)  can  travel  from  the  sinus  to  the  ven- 


OPPOSITE  ACTIONS  OF  VAGUS 


69 


tricle  and  cause  it  to  contract  without  causing 
the  auricle  to  contract.65  Yet  there  are  cases  in 
which  the  vagus  produces  complete  stoppage  of 
the  auricles,  so  that  one  can  hardly  suppose  any 


FIG.  22. — Diagram  to  illustrate  the  action  of  the  right  and  left  vagus  on 
the  heart  of  the  dog.  (Slightly  altered  from  A.  B.  Cohn.)  Speaking 
generally,  the  right  vagus  lessens  stimuli,  the  left  produces  block. 
The  right  vagus  goes  chiefly  to  the  smo-auricular  node,  or  pacemaker 
of  the  heart,  and  when  stimulated  it  stops  more  or  less  completely 
the  origination  of  stimuli  in  the  node,  and  thus  stops  the  auricles,  and 
generally  the  ventricles  also.  But  if  the  auricles  are  only  slowed  and 
not  stopped  entirely,  there  was  no  blocking  of  the  stimuli  from  them 
to  the  ventricles.  The  left  vagus  causes  some  slowing  of  the  auricles, 
but  blocks  the  passage  of  stimuli  from  the  auricle  to  the  ventricle. 
The  amount  of  this  may  vary  from  simple  prolongation  of  the  AV 
time  and  incomplete  heart-block,  to  complete  heart- block. 

stimuli  are  passing  from  them,  while  the  ven- 
tricle continues  to  beat  normally,  or  even  more 
quickly  than  normally,  if  the  accelerator  nerves 
are  stimulated  at  the  same  time  as  the  vagus.66 
Opposite  Effects  of  the  Vagus  on  Heart- 


70    PHYSIO  LOG  Y  OF  MAMMALIAN  HEART 

block. — Whilst  the  usual  effect  of  vagus  stimu- 
lation is  to  produce  more  or  less  complete 
heart-block,  yet,  when  heart-block  already  exists, 
stimulation  of  the  vagus  will  remove  it.  So  that, 
in  the  words  of  Gaskell,  "stimulation  of  the 
vagus  will  remove  the  block,  expedite  the 
recovery  of  the  tissue,  and  cause  every  contrac- 
tion-wave to  pass."67 

In  addition  to  this,  Gaskell  states  that  stimu- 
lation of  the  vagus  may,  at  one  time,  increase 
the  force  of  the  heart-beats  and  lessen  it  at 
another.68 

Even  though  they  should  be  due  to  two  kinds 
of  fibres  in  the  vagus,  it  is  not  easy  to  under- 
stand such  opposite  effects  except  by  supposing 
that  they  are  caused  by  some  kind  of  reinforce- 
ment and  interference  (Figs.  8  and  9,  p.  36 ;  cf. 
also  p.  61). 

The  nature  of  such  an  action  we  do  not  at 
present  understand,  but  neither  do  we  know 
the  nature  of  the  action  by  which  a  motor  nerve 
acts  upon  a  muscular  fibre  and  causes  it  to 
contract.  Both  actions  are  probably  more  or 
less  chemical,  and  future  investigations  will 
probably  explain  them. 

Trophic  Action  of  the  Vagus. — Gaskell  con- 
siders that  the  function  of  the  vagus  is  to  build 
up  anew  those  constituents  of  the  cardiac 
muscle  which  are  destroyed  during  contrac- 
tion.69 This  idea  receives  confirmation  from 
the  facts  that  after  death  the  heart  beats  longer 
if  the  vagi  have  previously  been  active,  and 
stops  sooner  if  the  vagi  had  been  cut.70  *  Section 

*  Joseph  and  Meltzer  (fourn.  of  Exp.  Med.,  1909,  vol. 


A  CCELERA  TING  NER  VES  OF  HEART     ^  \ 

of  the  vagi  during  life  also  causes  degeneration. 
The  action  of  the  vagus  appears  to  depend 
much  on  its  power  to  influence  tissue  change  in 
the  heart.  When  it  is  in  action  more  potassium 
is  given  off  by  the  heart  muscle.71  The  vagus 
will  not  slow  a  heart  perfused  with  a  solution  of 
sodium  chloride  only,  but  its  inhibitory  power 
returns  with  the  addition  of  potassium  and 
calcium.  It  is  necessary  for  these  to  be  in 
proper  proportion,  for  if  too  much  potassium  is 
present  the  heart  stands  still  in  diastole,  and  if 
calcium  is  in  excess  it  stands  still  in  systole.72 

Accelerating  Nerves  of  the  Heart. — The 
central  origin  of  these  nerves  has  not  been 
determined  with  the  same  exactitude  as  that  of 
the  inhibitory  nerves.  The  chief  accelerating 
nerves  appear  to  pass  down  in  the  cervical  part 
of  the  spinal  cord,  and  to  pass  from  it  by  the 
rami  communicantes  to  the  first  four  dorsal 
ganglia,  then  upwards  in  the  sympathetic  cord 
through  the  annulus  of  Vieussens  to  the  inferior 
cervical  ganglion,  and  thence  to  the  heart. 
There  seem,  however,  to  be  other  fibres  which 
have  an  accelerating  action.  In  the  frog  they 
occur  entirely  in  the  vagus,  and  this  nerve  also 
contains  accelerating  fibres  in  many  mammals.73 
Their  action  is,  however,  masked  by  the  more 
powerful  inhibitory  fibres,  so  that  stimulation  of 
the  vagus  trunk  causes  slowing  of  the  heart 
unless  the  inhibitory  fibres  have  been  paralysed 
by  atropine,  nicotine,  curare,  or  some  poison 

xi.,  Nos.  I  and  2)  found,  on  the  contrary,  that  stimulation 
of  the  vagi  before  or  after  death  hastened  the  occurrence 
of  rigor  in  the  hearr. 


72    PH YS1OLOG  Y  OF  MAMMALIAN  HEART 

having  a  similar  action.74  Then  vagus  stimula- 
tion causes  acceleration. 

As  the  vagi  have  the  character  of  spinal 
nerves  they  have  a  rapid  effect  on  the  heart, 
while  the  accelerating  nerves  belong  to  the 
sympathetic  system  and  have  a  slow  action. 
The  accelerator  nerves  can  act  on  the  ventricle 
without  acting  on  the  pacemaker  of  the  heart, 
for  they  will  quicken  the  ventricular  beats  when 
the  auricle  is  standing  completely  still  from 
stimulation  of  the  vagus.75 

The  accelerator  nerves  increase  the  strength 
as  well  as  the  rate  of  the  heart-beats.  They 
probably  act  through  the  ganglionic  cells  in  the 
nodes.  They  are  not  directly  antagonistic  to 
the  vagi.  When  both  are  stimulated,  the  after- 
result  is  increased  cardiac  efficiency.76 

Reflex  Stimulation  of  the  Inhibitory  and 
Accelerating  Nerves  of  the  Heart. — As  the 
function  of  the  heart  is  to  supply  blood  to  the 
whole  body,  one  would  naturally  suppose  it 
would  respond  to  a  call  from  any  part  of  the 
body  whatever,  and  this  is  indeed  the  case. 
Alterations  in  the  pulse  may  occur  from  stimuli 
proceeding  from  any  nerves  of  special  sense, 
optic,  olfactory,  acoustic,  or  glosso-pharyngeal ; 
from  the  nerves  of  the  skin,  of  the  muscles,  or  of 
the  viscera.77  The  nature  of  the  response 
depends  on  that  of  the  stimulus  ;  for,  when  this 
is  slight,  the  accelerating  nerves  appear  to 
respond  to  it  and  the  pulse  is  quickened,  but  if 
it  is  great,  the  vagus  is  stimulated  and  the  heart 
slowed.78 

Reflex   Stimulation    of    Inhibition. — Either 


VALVES  OF  THE  HEART  73 

mechanical  or  electrical  irritation  of  the  pericar- 
dium 79  or  of  the  surface  of  the  heart  will  cause 
the  ventricle  to  stand  still.  This  action  appears 
to  be  of  a  reflex  nature,  as  it  is  abolished  by 
painting  with  cocaine  before  applying  the 
stimulus.80  Reflex  stimulation  of  the  vagus, 
and  stoppage  of  the  heart  occurs  very  readily  on 
irritation  of  the  mucous  membrane  of  the  nose 
in  some  animals,  so  that  in  the  dog81  and  rabbit 
inhalation  of  a  strong  vapour  of  chloroform,  or 
of  ammonia,  will  stop  the  heart  instantly.82  It 
may  occur  also  from  other  parts  of  the  respira- 
tory passages  such  as  the  bronchi  and  lungs,83 
as  well  as  from  the  stomach  by  distension,84  or 
by  irritation  of  the  mucous  lining,85  and  from 
the  intestines.86  This  latter  reflex  is  important 
in  relation  to  slowness  or  intermission  of  the 
heart  from  gastric  irritation. 

Reflex  irritation  of  the  vagus  may  indeed 
occur  from  any  centripetal  nerve.87 

Valves  of  the  Heart. — If  the  valves  were 
not  present,  the  blood,  instead  of  being  forced 
steadily  onward  by  each  systole  of  the  auricles 
and  ventricles,  would  tend  to  regurgitate,  so  that 
the  heart  would  work  at  a  serious  disadvan- 
tage, and  much  of  its  energy  would  be  wasted. 
The  presence  of  the  valves  prevents  this.  In 
the  aorta  and  pulmonary  artery  we  have  three 
segments,  which  are  simply  brought  together 
like  those  of  an  ordinary  pump,  by  the  pressure 
within  the  artery  when  the  ventricle  ceases  to 
contract.  In  the  valves  which  separate  the 
auricle  from  the  ventricle  we  require  something 
more  than  this,  because  the  valves  are  large,  and 

G 


74    PH  YSJOLOG  Y  OF  MAMMALIAN  HEART 

when  the  walls  of  the  ventricle  approximate 
during  systole  the  thin  valves  would  be  driven 
back  into  the  auricle,  were  it  not  that  they  are 
attached  by  fine  cords  and  by  muscular  columns 


FIG.  28.— Diagram  of  a  simple  apparatus  for  demonstrating  the  action  of 
the  valves  of  the  heart,  and  ascertaining  their  competency.  It 
consists  of  an  ordinary  enema  syringe,  the  nozzle  of  which,  A,  is 
thrust  through  the  ventricle,  B,  from  the  inside,  and  kept  in  place  by 
a  thick  rubber  ring,  C.  D  is  the  auriculo- ventricular  ring;  G,  the 
valves ;  and  F,  the  musculi  papillares. 

which,  contracting  with  the  rest  of  the  ventricle, 
or  even  a  little  before  it,  draw  the  valves  down- 
wards and  prevent  them  from  being  forced  back 
into  the  auricles88  (Fig.  23). 

The  action  of  these  valves  is  aided   by  the 


contraction  of  the  muscular  fibres  around  the 
auriculo-ventricular  orifices,  which  are  greatly 
lessened  in  diameter,  so  much  so  that  one 
might  say  that  even  imperfect  valves  might 
close  them  (b  and  c,  Fig.  24) ;  whereas,  when 
the  cardiac  contraction  is  feeble  the  orifices 
may  be  too  large  to  be  completely  covered,  and 
thus  a  certain  amount  of  regurgitation  may 


FIG.  24.— (a)  Heart  fully  distended,  showing  insufficiency  of  the  valves 
to  close  the  mitral  and  tricuspid  orifices.  (6)  Heart  in  full  systole, 
showing  the  mitral  and  tricuspid  orifices  so  diminished  by  the 
muscular  contraction  that  the  valves  close  them  easily,  (c)  The  same 
heart  as  in  6,  from  another  point  of  view. 

The  casts  of  the  heart  from  which  the  above  figures  are  taken  were 
made  by  Mr  Franz  Joseph  Steger,  26  Talstrasse,  Leipzig,  and  were 
drawn  by  Mr  T.  P.  Collinga,  London.  They  were  originally  described 
by  F.  Hesse  (Arch.  f.  Anat.  u.  Physiol.,physiol.  AUg.,  1880,  p.  823). 

take  place  even  though  the  valves  themselves 
are  perfectly  healthy  (a,  Fig.  24).89 

The  temporary  mitral  murmurs  frequently 
heard  in  cases  of  cardiac  weakness  are  probably 
due  to  this  cause,  and  as  the  heart  recovers 
strength  they  disappear. 

Sounds  of  the  Heart. — The  closure  of  the 
valves  in  the  heart  occasions  sounds  which  can 
be  heard  by  putting  the  ear  to  the  chest  wall, 
and  they  can  be  still  better  localised  by  the  use 


76    PHYSIO  LOG  Y  OF  MAMMALIAN  HEART 

of  a  stethoscope.  When  we  do  this  we  hear 
sounds  which  are  well  imitated  by  the  syllables 
"  lub-dup,"  close  to  one  another.  These  syllables 
follow  one  another  quickly,  and  then  comes  an 
interval,  which  represents  the  diastole  of  the 
heart.  The  credit  of  showing  that  the  second 
sound,  "dup,"  is  caused  by  the  closure  of  the 
aortic  valves  belongs  to  C.  J.  B.  Williams  and 
the  committee  in  which  he,  Hale,  and  Glen- 
dinning  took  part.90  They  showed  that  when 
the  aortic  valves  were  destroyed  the  sound 
disappeared.  The  causation  of  the  first  sound, 
however,  has  given  rise  to  a  great  deal  of  dis- 
cussion. Some  authors  have  considered  it  to 
be  a  valvular  sound,  and  due  to  the  flapping 
together  of  the  auriculo  -  ventricular  valves ; 
whilst  others,  like  Magendie,  have  thought  it  to 
be  caused  by  the  striking  of  the  apex  against 
the  chest  wall;  and  yet  others  have  looked 
upon  it  as  being  a  muscular  sound,  due  to  the 
ventricular  contraction.  There  seems  to  be 
little  doubt  now,  from  the  experiments  of 
Ludwig,  Dogiel,91  and  others,  that  the  first 
sound  is  chiefly  muscular,  and  brought  about 
by  the  contraction  of  the  ventricle ;  but  the 
experiments  of  Ottomar  Bayer92  in  Ludwig's 
laboratory  demonstrated  that,  apart  from  the 
muscular  sound,  a  distinct  valvular  click  could 
be  obtained  by  the  closure  of  the  auriculo- 
ventricular  valves  in  a  dead  heart ;  whilst 
Williams  and  his  confreres  found,  in  addition, 
that  the  first  sound  was  intensified  by  allowing 
the  exposed  heart  to  beat  against  a  piece  of 
board.93  We  may  thus  consider  that  there  are 


SOUNDS  OF  THE  HEART  77 

three  factors  which  all  take  part  in  the  produc- 
tion of  the  first  sound,  viz.,  (i)  the  ventricular 
contraction ;  (2)  the  closure  of  the  auriculo- 
ventricular  valves ;  and  (3)  the  impulse  of  the 
apex  against  the  chest  wall. 

As  we  would  expect,  the  first  sound  is  heard 
most  loudly  over  the  apex,  which  is  the  point  of 
the  chest  wall  nearest  to  the  ventricle.  The 
second  sound  is  heard  more  sharply  over  the 
aortic  valves,  which  lie  beneath  the  left  side  of 
sternum  at  about  the  level  of  the  third  inter- 
costal space,  but  is  heard  still  better  at  the  point 
where  the  aorta  most  nearly  approaches  the 
sternum  at  its  right  edge,  and  at  the  level  of  the 
second  intercostal  space  or  third  costal  cartilage. 
Gibson94  has  described  a  third  sound  occurring 
occasionally  after  the  second. 

Double  Nature  of  the  Heart. — For  the  sake 
of  simplicity,  I  have  to  a  great  extent  spoken  of 
the  heart  as  if  it  consisted  only  of  the  left  side, 
but  we  have  in  man,  as  in  other  mammals,  really 
two  hearts  joined  together  in  one,  the  right  and 
the  left ;  the  right  sending  the  blood  through 
the  lungs  for  the  purpose  of  aerating  it,  and  the 
left  sending  the  blood  through  the  body  in  order 
to  nourish  the  tissues.  Both  hearts  receive  the 
blood  from  the  large  veins  into  the  auricles, 
which,  contracting,  send  it  on  to  the  ventricles, 
and  thence  it  is  propelled  by  the  right  ventricle 
into  the  pulmonary  artery,  and  by  the  left 
ventricle  into  the  aorta.  As  I  have  mentioned 
before,  both  the  vena  cava  and  the  pulmonary 
veins  have  the  power  of  rhythmically  independ- 
ent pulsation  apart  from  the  auricle,  and  the 


78    Pff  YS10LOG  Y  OF  MA  MM  A  LI  AN  HEART 

cardiac  beat  may  sometimes,  though  probably 
not  always,  originate  in  them  (p.  21). 

Right  Ventricle. — The  resistance  which  the 
right  ventricle  has  to  overcome  in  driving  the 
blood  through  the  pulmonary  artery  is  only 
about  one-third  that  presented  by  the  aorta, 
and,  consequently,  the  right  ventricle  is  only 
about  one-third  the  strength  of  the  left.  The 
tricuspid  valves,  which  separate  the  right  ven- 
tricle from  the  right  auricle,  are  much  more 
easily  rendered  incompetent  by  distension  of 
the  ventricle  than  are  the  mitral  valves,  and  this 
tendency  to  incompetency  has  been  regarded, 
and  I  think  with  truth,  as  a  safety-valve,96 
preventing  the  stoppage  of  the  right  ventricle 
by  over-distension,  and  allowing  the  blood  to 
pass  back  into  the  venous  reservoirs,  of  which  I 
have  already  spoken. 

In  cases  where  the  arterial  tension  is  abnor- 
mally high  and  the  danger  of  cerebral  haemor- 
rhage is  consequently  great,  a  safety-valve  action 
sometimes  occurs  also  in  the  left  ventricle,  which 
dilates,  so  that  the  mitral  valves  become  incom- 
petent and  allow  a  certain  amount  of  regurgitation 
to  take  place.  This  lowers  the  arterial  tension 
and  lessens  the  risk  of  apoplexy. 


LITERATURE. 

Purkinje,  Breslau.  Schles.   Gesellsch.  Uebersicht,  1841, 

p.  86. 
Nicolai,    Nagel's   Handbuch  d.  Physiol.  d.  Menschen, 

vol.  i.,  p.  80 1  (Braunschweig :  F.  Vieweg  u.  Sohn, 

1909). 


LITERATURE  OF  CHAPTER  III  79 

3  Kronecker  and  Imchanitzky,  Archives  Internationale s 

de  Physiol.f]u\\\&\.  1906,  vol.  iv.,  pp.  1-17  ;  and  pi.  i. 

4  Martin   Flack,   "The    Heart,"  Farther   Advances  in 

Physiology,  edited  by   Leonard  Hill,    F.R.S.,  p.  38 
(London  :  Edward  Arnold,  1909). 
6  Flack,  op.  cit.,  p.  45. 

6  Lee,  Robert,  Phil.  Trans.,  1849,  P-  47- 

7  Retzius,  Biol.   Untersuch.,  New  Series,  vol.  iii.,   1892, 

p.  49. 

8  Ramon  y  Cajal,  Gaz.  sanitat  de  Barcelona,  loth  August 

1890  and  loth  April  1891,  quoted  by  Retzius. 

9  Berkeley,  The  Johns  Hopkins  Hospital  Reports,  1894-5, 

vol.  iv.,  p.  248  et  seq. 

10  J.  F.   Heymans  and  L.  Demoor,  "Etude  de  1'Inner- 

vation  du  Coeur  des  Vertebres,"  Memoires  couronnfo, 
par  I' Academic  Roy,  de  Medicine  de  Belgique,  1894, 
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11  A.    Frohlich  (and  von  Basch),   Zentralb.  /.  Physiol., 

1904,  vol.  xviii.,  p.  693. 

12  Bayliss  and  Starling,  Proceedings  of  the  Royal  Society, 

vol.  1.,  pp.  213  and  214. 

13  Stefani  and  others,  quoted  by  Tigerstedt,  Lehrb.   d. 

Physiol.  d.  Kreisl.,  p.  142  et  seq. 

14  Ludwig  and  Hoffa,  Ztschr.  f.  rat.  Med.,  1850,  p.  129  ; 

Kronecker,  Ludwig 's  Festgabe,  1874,  P-  I9I- 

15  Bowditch,  Ber.  d.  sacks.  Gesellsch.,  1871,  p.  687,  and 

Ludwigs  Arbeiten,  6ter  Jahrg.,  p.  174 ;  Ranvier, 
Leqons  cfAnat.  Gen.,  1877-8,  "Appareils  nerv.  ter- 
minaux,  etc."  (Paris,  1850),  p.  175. 

10  Gaskell,  S  chafer's  Textbook  of  Physiol.,  vol.  ii.,  p.  194  ; 
Journ.  of  Physiol.,  1880,  vol.  iii.,  p.  48  et  seq.  and 

P.  369- 

17  Engelmann,  P  finger's  Archiv,  1896,  vol.  Ixii.,  p.  543 

et  seq. 

18  Tawara,     Reizleitungssysteme    d.    Saugethierherzens, 

(Jena,  1906),  pp.  134  and  150. 

19  Martin  Flack,  op.  cit.,  p.  46. 

20  Keith,  Journ.  of  Anat.  and  Phys.,  1908,  vol.  xlii.,  p.  i. 

21  Keith  and  Flack,  op.  cit.,  vol.  xli.,  p.  172  ;  Lancet,  nth 

August  1906,  p.  359. 

22  Tawara,  op.  cit.,  p.  134. 

23  Flack,  Farther  Advances  in  Physiology,  p.  38. 


8o  LITERATURE 

24  Stanley   Kent,   Proc.   Physiol.  See.,   I2th    November 

1892,  No.  6,  p.  24  ;  and/ourn.  of  Physiol.,  vol.  xiv., 

1893,  p.  233. 

26  W.  His,  jun.,  Arbeiten  a.  d.  Med.  Klinik  zu  Leipzig 

herausgegehen  von  Dr   H.   Curschmann  (Leipzig : 
F.  C.  Vogel,  1893),  p.  23. 
8  Tawara,  op.  cit.,  p.  134  et  seq.  and  p.  150. 

27  Erla.nger,Amer./oum.  of  Med.  Set'.,  1908,  New  Series, 

vol.  cxxxv.,  p.  797. 

28  Jas.  Mackenzie,  Diseases  of  the  Heart,  p.  160  (London, 

•1908). 

29  A.  E.  Cohn,  Journ.  of  Exper.  Med.,  1912,  vol.  xvi.,  p. 

755- 

10  Wooldridge,  Ludwigs  Arbeiten,  and  Arch.  f.  Anat.  u. 
Physiol.,  1883,  p.  533. 

31  Tigerstedt,   Ludwigs    Arbeiten,    1884,   and   Arch.   f. 

Anat.  u.  Physiol.,  1884,  p.  503. 

32  MacWilliam,  Journ.  of  Physiol.,  1886,  vol.  ix.,  p.  177. 
83  Joseph  Erlanger,  Journ.  of  Ezper.   Med.,   vol.   viii., 

p.  13  (New  York,  1906). 
34  Lewis,    Mechanism  of  the  Heart    Beat,    pp.   97-112 

(London,  1911). 
36  Flourens,   Compt.  rend.,  1858,   torn.   47,   p.  813;  and 

Recherches  experiment  s.  les  Propriete's  et  Fonctions 

du  Systeme  Nerueux,   2nd   edition,    p.   201    (Paris, 

1842). 
}6  Kronecker  and  Schmey,  Sitzungsb.,  d.  Akad.  d.  Wtss. 

zu  Berlin,  1884,  p.  87. 
31  G\&r\iQ,Arch.  f.  Anat.  u.  Physiol.,  1873,  vol.  vii.,  p.  583. 

38  MacWilliam,  Journ.  of  Physiol.,  1887,  vol.  viii.,  p.  300. 

39  See   literature  in  F.  B.  Hermann's  article  in  Nagefs 

Handb.  d.  Physiol.  d.  Menschen,  Bd.  i.,  p.  239  (Braun- 
schweig, 1909). 

40  Lewis,  Mechanism  of  the  Heart  Beat,  p.  229  (London, 

1911). 

41  Meyer  and   Gottlieb,  Exper.   Pharmacologie,   p.    217 

(Berlin  u.  Wien,  1910). 

42  Vide  Tigerstedt,  Lehrb.  d.  Physiol.  d.  Kreisl.,  p.  228  ; 

Gibson,  Nervous  Affections  of  the  Heart,  p.  24 
et  seq.  (Pentland:  London  and  Edinburgh,  1904). 
A.  Morison,  Nervous  Systems  and  Visceral  Disease 
(Pentland  :  London  and  Edinburgh,  1899) ;  Wool- 


LITERATURE  OF  CHAPTER  111  81 

dridge,  Ludwig1  s  Arbeiten,  1883,  and  Arch.f.  Anal. 
u.  Physiol.,  1883,  p.  524. 

43  Gaskell  in   Schafer's    Textbook  of  Physiol.,    vol.   ii., 

p.  200. 

44  Schweigger,   Seidel,    Unpublished  Notes  of  Lectures 

given  in  Ludwig' s  Laboratory  in  Summer  of  1869. 

45  Heitler,  Wiener  klin.  Wochenschr.,  1898. 

46  Goltz,  Centralb.  d.  med.  Wiss.,  1863,  pp.  17,  497,  and 

Virch.  Arch.,  vol.  xx.,  p.  10  et  seq.;  Budge,  Arch.f. 
Physiol.  Heilk.,  1846,  vol.  v.,  p.  588  ;  Gurboki, 
Pfluger's  Arch.,  1872,  vol.  v.,  p.  289  ;  Wooldridge, 
Ludwig 's Arbeiten,  1883,  andArcb./.  Anat.  u.  Physiol , 
1883,  p.  522  et  seq. 

47  Ludwig  and  Cyon,  Ludwig1  s  Arbeiten  for  1866,  p.  128. 
J8   Vide   Hill,   Schafer's    Textbook  of  Physiol.,  vol.   ii., 

pp.  59  and  60  ;  and  Tigerstedt,  op.  cit.,  p.  279. 
49  Se wall  and  Steiner,  Journ.  of  Physiol.,  1885,  vol.  vi., 

p.  174- 
•°  Koster  and  Tscbermak,  quoted  by  Hofmann,  NageFs 

Handbuch  d.  Physiol.,  Bd.  i.,  p.  283. 

51  Variations  occur,  and  these  are  described  and  literature 

given  by  Tigerstedt,  op.  cit.,  p.  247. 

52  F.  Franck,  Archiv  d.  Physiol.,  1891,  p.  583,  Kronecker. 

53  Vide  Tigerstedt,  op.  cit.,  p.  253  et  seq. 

54  Bonders,  Pfluger's  Atchiv,  1868,  vol.  i.,  338  et  seq., 

and  1872,  vol.  v.,  p.  6. 

56  Schmiedeberg,  Grundriss  d.  Pharmacologie,  p.  137 
(Leipzig :  Vogel,  1902). 

56  A.  Waller,  Gaz.  med.  de  Paris,  1856,  p.  420. 

57  Vide  F.  Hofmann  in  NagePs  Handb.  d  Physiol,  Bd.  i., 

p.  276. 

68  A.  B.  Meyer,  Das  Hemmungsnervensy stem  des  Herzens, 
p.  60. 

59  Gaskell,  Proc.  Roy.  Soc.,  1881,  vol.  xxxiii.,  p.  201  ; 
Schmiedeberg,  Ludwigs  Arbeiten,  6**'  Jahrg.  for 
1871,  p.  34  et  seq.  (Leipzig:  Hirzel,  1872),  and 
Sitzungsb.  d.  k.  sack.  Gesellsch.  d.  Wiss.,  vol.  xxiii., 
p.  148  et  seq. 

90  Gaskell,  Journ.  of  Physiol.,  1884,  vol.  v.,  p.  46. 

61  Hennann's  Handbuch  d.  Physiol.,  vol.  v.,  part  2,  pp. 

444  and  450. 

62  Ibid.,  vol.  iv.,  part  2,  p.  243. 


82  LITERATURE 

83  Gaskell,  Schafer's  Textbook  of  PhysioL,  vol.  ii.,  p.  209. 
01  A.  E.  Cohn,  Journ.  of  Exp.  Med.  1912,  vol.  xvi.,  p.  732  ; 

vide  also  Kraus  and  Nicolai,  Das  Electrokardio- 
gramm,  p.  147  (Leipzig:  Veit  &  Co.,  1910). 

65  Gaskell,  Journ.  of  PhysioL,  1882,  vol.  iii.,  p.  376. 

66  Bayliss  and  Starling,  Journ.  of  PhysioL,  1892,  vol.  xiii., 

P.  414. 

07  Gaskell,  Journ.  of  PhysioL,  1882,  vol.  iii.,  p.  377. 

08  Gaskell,  Proc.  Roy.  Soc.,  1881,  vol.  xxxiii.,  p.  203. 

09  Gaskell,  Journ.  of  PhysioL,  1886,  vol.  vii.,  p.  50. 

70  Brown-Se'quard  and  others,  quoted  by  Tigerstedt, 
op  cit.,  p.  258  et  seq.;  Traube,  Gesammelte 
Beitrage,vo\.  i.,  p.  381  (Berlin,  1871) ;  Eichhorst,  Die 
trophischen  Beziehungen  der  Nervi  Vagi  zum  Herz- 
muskel,  p.  1 8  (Berlin,  1879);  Wassilieft,  Zeitschr.f. 
Klin.  Med.,  1881,  vol.  iii.,  p.  316. 

TI  Howell  and  Duke,  Amer.  Journ.  of  Physiol.,  1908,  vol. 
xxi.,  p.  51. 

2  Vide  Meyer  and  Gottlieb's  Pharmacologie,  p.  229. 

3  Vide  Tigerstedt,  op.  cit.,  p.  260  et  seq. 

74  Rutherford,  Journ.  of  A nat.  and  PhysioL,  1869,  vol.  iii., 

p.  408  ;  Boehm,  Arch.f.  exp.  Path.  u.  Pharm.,  1875, 
vol.  iv.,  p.  363  ;  Dale,  Laidlaw,  and  Symons,  Journ. 
of  PhysioL,  1910,  vol.  xli.,  p.  i  et  seq. 

75  Bayliss  and  Starling,  Journ.  of  PhysioL,  1892,  vol.  xiii., 

p.  414. 
Tigerstedt,  op.  cit.,  p.  272. 

77  Tigerstedt,  op.  cit.,  p.  289. 

78  Simanowsky,  quoted  by  Tigerstedt,  op.  cit.,  p.  288. 

79  Heitler,  Wiener  klin.  Wochenschr.,  1898. 

80  A.   Frohlich  and   von    Basch,   Zentralb.  f.    PhysioL, 

1904,  vol.  xviii.,  p.  693. 

81  Frangois  Franck,  Trav.de  Laboratoire  de  Marey,  1876, 

vol.  ii.,  p.  226. 

82  Lauder   Brunton,  "Experiments,"  vide   "Shock  and 

Syncope,"   Practitioner,  1873,  v°l-   xi->  P-  24^5  also 
Kratschmer,  Wiener  Sitzungsb.,  1870,  vol.  Ixii.,  p.  24. 
53  Frangois  Franck,  op.  cit.,  1880,  vol.  iv.,  p.  378. 

84  Mayer    and    Pribram,    Sitzungsb.    d.    k.    Akad.    d. 

Wiss.  Math.  Nat.  CL,  1872,  vol.  Ixvi.,  p.  102. 

85  Hermann  and  Ganz,  PflugefsArchiv,  1870,  Bd.  iii.,  p.  8. 

86  Tigerstedt,  op.  «'/.,  p.  282  et  seq.,  and  p.  289. 


LITERATURE  OF  CHAPTER  111  83 

87  Tigerstedt,  op.  at.,  p.  289. 

88  Lauder  Brunton,  St  Bartholomew's  Hospital  Reports 

1878,  vol.  xv.,  p.  283. 

89  Ludwig  and  Hesse,  Arch.  f.  Anat.  u.  Physiol.,  1880, 

Anat.  Abtg.,  p.  344 ;  Macalister,  Brit.  Med.  Journ., 
28th  October  1882,  p.  825. 

90  Sixth  Report  of  the  British  Association,  1836,  p.  265. 

91  Ludwigs  Arbeiten,  1878,  p.  78. 

92  O.  Bayer,  Arch.f.  Heilk.,  1870,  vol.  xi.,  p.  157. 

93  Report  of  the  Fifth  Meeting  of  the  British  Association, 

1835,  p.  246. 

94  Gibson,  Lancet,  1907,  vol.  ii.,  p.  1380. 

96  Wilkinson,  Guy's  Hospital  Report,  1837,  p.  132. 


PHYSIOLOGY  OF  VESSELS  :    BLOOD-PRESSURE 

Aorta — Arteries,  Arterioles  and  Capillaries — Vaso-motor 
Nerves — Dilating  Nerves — Elongation  of  Muscle(?) — 
Contraction  of  Veins — Rhythmical  Contraction  of 
Vessels — Stimulation  of  Blood-vessels  from  with- 
out— Stimulation  from  within — Internal  Secretions — 
Toxins — Double  Function  of  the  Kidney — Effect  of 
.  Heat  and  Cold  on  the  Systemic  Circulation — Fever — 
Effect  of  Heat  and  Cold  on  the  Pulmonary  Circula- 
tion— Blood-pressure — Schema  of  the  Circulation — 
Kymographs — Blood-pressure  in  Animals— In  Man. 

Aorta. — On  looking  at  the  aorta,  one  would 
say  that  it  is  entirely  composed  of  fibrous  tissue, 
and  consequently  is  not  likely  to  possess  any 
contractile  power;  and  yet  it  would  appear  to 
have  such  a  power,  for  in  the  case  of  a  criminal 
executed  by  decapitation  at  Wiirzburg,  it  was 
found  to  contract  on  the  application  of  electricity 
shortly  after  death.1 

Arteries  and  Capillaries. — As  we  pass  down 
the  arterial  system  the  muscular  fibres  become 
more  developed,  and  in  the  arterioles  we  find  a 
continuous  muscular  layer,  while  in  the  capil- 
laries we  have  nothing  but  contractile  cells. 
Just  as  in  the  case  of  the  heart,  where  we  have 

84 


VASO-MOTOR  AND  DILA TING  NER  VES    85 

two  kinds  of  nerves  having  an  opposing  action, 
so  we  have  in  the  vessels,  nerves  which  cause 
contraction,  and  others  which  cause  dilatation. 
When  working  with  Schweigger-Seidel  in 
Ludwig's  laboratory  in  1869,  I  made  a  number 
of  observations  on  the  nerves  of  the  arterioles 
and  veins,  but  these  were  not  published,  as  I 
did  not  discover  anything  new.  I  tried  in  vain 
to  find  any  evidence  of  nerve  fibres  entering  the 
muscular  cells  of  the  arterioles,  but  could  never 
observe  it.  All  that  I  could  find  was  a  regular 
network  of  minute  nervous  fibrils  running  over 
the  surface  of  the  muscular  layer.  At  the  points 


PIG.   25.— Diagram  of  the  nerve  fibrils,  ramifying  like  a  net  over  the 
muscular  layer  of  an  arteriole. 

where  these  fibrils  cross  there  are  small  thicken- 
ings or  knots,  but  nothing  at  all  like  ganglion 
cells  (Fig.  25).  The  same  has  been  observed 
by  Heymans  and  Demoor  in  the  apex  of  the 
rabbit's2  heart  and  in  the  coronary  arteries. 

Vaso-motor  Nerves.  Dilating  Nerves.  Elon- 
gation of  Muscle  (?). — The  vaso- motor  system, 
as  I  have  already  said,  has  its  chief  centre  in 
the  medulla  oblongata,  but  it  has  subsidiary 
centres  in  the  spinal  cord  itself,  and  in  the 
ganglionic  chain  of  the  sympathetic.  When  the 
vaso-motor  centres  or  the  trunks  of  the  vaso- 
motor  nerves  are  irritated,  the  vessels  contract ; 


86  PHYSIOLOGY  OF  VESSELS 

but  there  are  other  nerves  which,  when  irritated, 
cause  dilatation  instead  of  contraction,  and  this 
dilatation  is  greater  than  that  which  occurs  on 
the  division  of  the  vaso-motor  fibres  supplying 
the  vessel.8  This  fact  is  generally  explained  by 
supposing  that  irritation  of  the  dilating  nerves 
has  an  inhibitory  action  upon  local  vaso-motor 
mechanisms  close  to  the  vessels ;  though,  for 
my  own  part,  I  should  be  inclined  to  accept  the 


Fio.  26 — Diagram  to  illustrate  the  hypothetical  transverse  contraction  of 
muscle,  (a)  Muscle  in  relaxed  condition,  (6)  in  contraction,  (c)  in 
elongation. 

much  simpler  explanation  that  a  transverse  as 
well  as  a  longitudinal  contraction  may  occur  in 
the  muscular  cells  of  the  arterioles,  and  such  a 
transverse  contraction  would  elongate  each  cell, 
and  dilate  the  vessel  just  as  the  longitudinal 
contraction  would  shorten  and  thicken  the  cell, 
and  thus  contract  the  vessel  (Fig.  26).  In  many 
instances,  dilatation  or  dilation  is  connected 


CONTRACTION  OF  VEINS  87 

with  peripheral  ganglia — for  example,  in  the 
sub-maxillary  gland,  and  in  the  nervi  erigentes — 
but  that  it  is  always  due  to  such  nervous  causa- 
tion is,  I  think,  doubtful.  For  a  good  while  the 
contractility  of  capillaries  was  doubted,  but  the 
observations  of  Strieker  and  others  have  now, 
I  think,  put  this  fact  beyond  dispute.4  When 
working  under  Ludwig's  direction  I  also  noticed 
that  local  irritation  would  sometimes  cause,  not 
contraction,  but  dilatation  of  an  arteriole.5 
Similar  observations  were  made  by  Gunning 
and  Cohnheim  in  the  frog ;  so  that,  just  as  the 
effect  of  nerves  upon  the  heart  itself,  to  the 
exclusion  of  muscular  irritability,  is  now  recog- 
nised to  be  wrong,  so  in  all  probability  the 
properties  of  the  muscular  elements  of  the 
arterioles,  like  those  of  the  heart,  will  by  and 
by  receive  more  attention  than  they  have 
hitherto  done. 

Contraction  of  Veins. — By  looking  at  the 
back  of  the  hand,  anyone  can  observe  what 
great  differences  occur  from  time  to  time  in  the 
size  of  the  veins.  The  dependence  of  venous 
contraction  upon  vaso-motor  nerves  was  shown 
by  Mall  in  Ludwig's  laboratory.6  He  found 
that  irritation  of  the  splanchnic  nerves  caused 
the  exposed  portal  vein  to  contract  so  forcibly, 
that  when  the  irritation  was  long  continued  the 
lumen  of  the  vein  was  quite  abolished.  Irrita- 
tion of  the  sciatic  causes  the  superficial  veins 
of  the  hind  legs  to  contract  in  animals.7  Adrenin 
applied  to  ring  preparations  of  peripheral  veins 
causes  them  to  contract  in  the  same  way  as 
arteries,  and  when  applied  to  rings  from  the 


88  PHYSIOLOGY  OF  VESSELS 

superior  cava  near  the  heart,  causes  them  to 
beat  rhythmically.8 

Rhythmical  Contraction  of  Vessels. — Rhyth- 
mical contraction  of  the  veins  was  observed  to 
exist  by  Wharton  Jones,9  Schiff,10  and  Vulpian.11 
The  arteries  also  contract  rhythmically  under 
the  influence  of  the  vaso-motor  centre,  and  give 
rise  to  periodic  pulsations  which  are  coincident 
with  respiration.  In  addition  to  these,  however, 
the  arteries  themselves  pulsate 12  periodically.13 
It  is  difficult  to  see  this  pulsation  in  healthy 
people,  but  it  can  be  well  observed,  as  a  rule, 
in  patients  suffering  from  aortic  regurgitation. 
In  such  cases  the  face  is  usually  pale,  but  if 
the  finger-nail  be  rapidly  drawn  across  the  fore- 
head, a  red  streak  appears  which  alternately 
widens  and  narrows,  and  this  movement  on 
careful  observation  will  be  seen  to  show  three 
rhythms.  The  first  coincides  with  the  pulse,  and 
occurs  about  60  to  80  times  per  minute ;  the 
second  with  respiration,  about  18  or  20  times;  and 
the  third,  or  capillary  rhythm,  about  three  times 
per  minute,14  or  once  in  20  seconds.  Douglas 
Cow  has  observed  rhythmical  contraction15  in 
strips  of  vessels  treated  with  ergot  and  adrenalin. 
The  average  time  was  25  seconds.  I  have  my- 
self felt  a  similar  rhythm  in  the  radial  artery  with 
a  cycle  of  20  pulsations  or  3  to  4  per  minute. 

Stimulation  of  Blood-vessels  from  -without. 
— It  is  difficult  to  explain  the  various  local 
alterations  of  the  circulation,  if  we  look  entirely 
to  the  nervous  system  for  an  explanation  of 
them  ;  whereas  the  explanation  is  easy  if  we 
acknowledge  the  power  of  vessels  to  contract, 


INTERNAL  SECRETIONS  89 

or  dilate  from  alterations  in  their  contractile 
element  apart  from  the  nervous ;  although,  just 
as  in  the  heart,  we  must  fully  recognise  the 
enormous  influence  of  the  nervous  system  upon 
the  vessels.  Thus,  when  we  apply  a  mustard 
poultice  to  the  skin,  the  rapid  dilatation  of  the 
vessels  and  consequent  redness  which  immedi- 
ately follows  the  application  are  probably  due 
to  nervous  influence.  In  this  case  the  nervous 
plexus  (Fig.  25)  seems  to  act  as  a  reflex  centre 
for  dilatation  of  the  vessels,  although  it  contains 
no  ganglionic  cells.  The  permanent  redness, 
which  may  remain  for  several  days,  is  more 
likely  to  be  due  to  a  local  alteration  in  the 
vessels  themselves  (Ninian  Bruce).16 

Stimulation  of  Vessels  from  -within. — A 
still  more  important  question,  however,  than 
the  effect  of  irritation  of  the  vessels  from  the 
outside,  is  that  of  stimulation  from  the  inside  by 
various  products  of  glandular  secretion,  or  tissue 
waste,  or  by  strain. 

Internal  Secretions. — The  first  discovery  of 
internal  secretion  was  made  by  Claude  Bernard, 
in  the  case  of  the  liver,  which,  as  he  found, 
poured  out  bile  into  the  bowel  (external 
secretion)  and  sugar  into  the  blood  (internal 
secretion).17  Of  late  years  it  has  been  found 
that  several  glands  which  have  no  external 
secretion  at  all  have  internal  secretions  of  the 
greatest  physiological  importance,  and  some  of 
these  play  a  great  part  in  regulating  the  con- 
traction of  the  capillaries  and  maintaining  the 
blood-pressure  at  a  proper  height.18  Thyroid 
gland  or  its  extract  when  taken  by  the  mouth 

H 


90  PHYSIOLOGY  OF  VESSELS 

dilates  the  peripheral  vessels,  makes  the  skin 
warm  and  moist,  and  quickens  the  pulse.19  The 
suprarenal  and  pituitary  bodies  and  their  ex- 
tracts have  an  action  opposite  to  the  thyroid.20 
It  is  supposed  that  they  constantly  pour  these 
secretions  into  the  circulation,21  and  thus  main- 
tain the  arterial  tension.  When  the  medullary 
part  of  the  suprarenal  gland  is  diseased,  the 
heart  becomes  feeble,22  the  blood-pressure  low, 
and  the  digestion  weak ;  whilst  if  the  cortex 
also  is  diseased  the  peculiar  bronzing  of  the 
skin  also  appears,  and  completes  the  picture 
of  Addison's  disease.23  Extract  of  the  cortex 
of  suprarenal  glands  when  injected  directly  into 
the  circulation  causes  stimulation  of  the  heart 
and  great  contraction  of  the  arterioles,  so  that 
the  blood-pressure  rises  enormously.24  This 
rise  only  lasts  a  short  time,  but  may  be  renewed 
by  a  fresh  injection.  In  life  the  gland  probably 
secretes  slowly  but  continuously,  so  that  the 
tension  is  maintained  without  rising  too  high. 
The  pituitary  body  consists  of  three  parts,  of 
which  the  intermediate  one  appears  to  secrete 
substances  which  have  a  mixed  action,  some 
of  them  causing  contraction  of  the  blood-vessels 
in  the  general  circulation,  but  dilating  those 
of  the  kidney,  and  producing  diuresis.  Others 
cause  contraction  of  the  renal  vessels,  and  lessen 
the  urinary  secretion.25 

Toxins. — Substances  having  a  similar  action 
to  suprarenal  extract,  but  more  prolonged,  have 
been  made  synthetically.  They  all  belong  to 
the  class  of  amines  or  ammonias  in  which 
hydrogen  is  replaced  by  an  organic  radical.20 


DOUBLE  FUNCTION  OF  THE  KIDNEY   91 

Two  such  amines  have  been  obtained  from 
putrid  meat,  and  also  when  bacilli  from  human 
faeces  are  added  to  broth  containing  tyrosin, 
which  is  one  of  the  products  of  pancreatic 
digestion.27 

Double  Function  of  the  Kidney. — In  addition 
to  its  power  of  secreting  urine,  it  is  probable  that 
it  has  an  internal  secretion  also.28  It  has,  more- 
over, very  considerable  metabolic  power,  for 
Schmiedeberg  found  that  if  blood  containing 
benzoic  acid  is  circulated  through  an  excised 
kidney  the  urine  secreted  contains  hippuric 
acid.29  It  is  possible  that  the  rise  of  blood- 
pressure  in  nephritis  is  due  either  to  some 
alteration  of  metabolic  power,*  or  else  to 
lessened  power  to  excrete  the  substances  which 
tend  to  raise  the  tension.  Extract  of  kidney 
itself  seems  to  raise  the  tension  somewhat 
when  injected  into  animals,30  but  this  effect  is 
much  more  marked  when  one  or  both  kidneys 
have  been  removed,  so  that  excretion  of  the 
tension-raising  substances  is  prevented,31  or  in 
persons  suffering  from  renal  disease.32  Removal 
of  portions  of  the  kidney  causes  a  rise  of 
blood -pressure  in  animals  without  the  injec- 
tion of  any  kidney -extract.83  In  renal  disease 
it  varies  inversely  as  the  extent  of  kidney 
present. 

Probably  the  loss  of  some  metabolic  or  excre- 
tory power,  due  to  shrinking  of  the  renal  cortex 

*  Jaarsveld  and  Stokvis  found  (Arch.  f.  exp.  Path, 
u.  Pharm.,  1879,  vol.  x.,  p.  295)  that  hippuric  acid  may 
undergo  conversion  into  benzoic  acid  in  the  body  of  some 
animals  and  of  persons  suffering  from  renal  disease. 


92  PHYSIOLOGY  OF  VESSELS 

in  chronic  interstitial  nephritis,  is  the  cause  of  the 
gradual  rise  of  blood-pressure  in  this  disease.  It 
often  rises  so  high  as  to  threaten  life,  either  from 
cardiac  failure  or  from  arterial  rupture.  This 
high  tension  appears  to  commence  by  increased 
resistance  to  the  passage  of  blood  through 
the  arterioles  and  capillaries.  By  some  it 
is  attributed  to  chronic  contraction  of  the 
arterioles  with  hypertrophy  of  their  muscular 
walls,34  by  others  to  a  fibroid  thickening.86  It  is 
probable  that  both  of  these  conditions  occur, 
but  for  my  own  part  I  am  inclined  to  believe 
that  the  arterial  contraction  plays  a  very  great 
part  in  it,  as  we  are  able  in  very  many  cases  to 
reduce  the  tension  by  means  of  appropriate 
medicines,  such  as  nitrites,  which  one  would 
hardly  do  if  it  were  entirely  or  even  mainly  due 
to  a  fibroid  condition.  This  view  also  enables 
us  to  understand  why  nitrites  sometimes  fail  to 
act,  for  if  the  high  tension  is  due  to  much  fibrosis 
and  little  spasm  they  cannot  lower  the  tension. 
High  tension  due  to  toxic  substances  reacts  on 
the  vessels  and  may  produce  atheroma  in  them, 
so  that  ultimately  functional  contraction  becomes 
complicated  by  organic  change.36 

Effect  of  Heat  and  Gold  on  the  Circulation. — 
Two  agents  which  have  a  very  marked  effect, 
both  upon  the  vessels  and  the  heart,  as  well  as 
on  muscular  tissue  generally,  are  heat  and  cold. 
When  we  put  the  hand  into  hot  water  we  find 
at  once  that  the  arteries  dilate  and  the  hand 
becomes  red,  showing  that  the  capillary  circula- 
tion is  free ;  but  we  notice  also  that  the  veins 
not  only  become  full,  but  become  lighter  in 


EFFECT  OF  HEAT  AND  COLD  93 

colour,  evidencing  that  the  blood  within  them  is 
more  arterial.  Heat  applied  to  the  heart 
quickens  its  pulsations,37  and  at  the  same  time 
increases  their  strength,  the  quickening  being 
chiefly  due  to  the  effect  of  the  heat  upon  the 
sinus  or  auricles,  and  the  increased  strength 
to  its  effect  upon  the  ventricle.38  Cold  has  an 
opposite  effect.  When  applied  to  the  extremities, 
it  makes  the  arteries  contract,  the  fingers  shrink 
and  become  pale,  though  after  a  while  the  veins 
appear  to  dilate,  and  the  skin  assumes  a 
bluish  colour  from  venous  congestion.  Cold 
applied  to  the  heart  makes  its  movements  both 
slower  and  feebler. 

It  is  evident  from  what  I  have  said  that  the 
local  action  of  either  heat  or  cold  upon  the 
vessels  and  heart  is  of  such  a  character  as  in 
itself  to  co-ordinate  the  effect  it  produces  upon 
both,  independently  of  a  nervous  system,  if 
applied  to  both  at  the  same  time ;  because 
when  heat  causes  the  vessels  to  dilate,  so  that 
a  larger  supply  of  blood  is  demanded,  it  also 
causes  the  heart  to  pulsate  more  quickly  and 
more  forcibly,  so  as  to  give  the  necessary 
supply.  When  the  arteries  are  contracted  by 
cold  and  a  small  amount  of  blood  only  can  pass 
through  them,  the  cold  acts  on  the  heart  also, 
slowing  and  weakening  its  contraction,  and  thus 
lessening  the  supply.  But  while  cold  and  heat 
may  act  nearly  equally  upon  the  extremities 
and  the  heart  of  a  frog,  it  is  not  so  in  warm- 
blooded animals,  where  the  temperature  of  the 
interior  of  the  body  remains  nearly  the  same, 
notwithstanding  the  extremes  of  heat  and  cold 


94  PHYSIOLOGY  OF  VESSELS 

to  which  the  extremities  may  be  subjected,  and 
in  them  it  is  necessary  to  have  a  nervous  system 
to  regulate  the  pressure  of  blood. 

Fever. — In  fever  the  increased  temperature 
of  the  body  stimulates  the  heart  and  dilates 
the  vessels,  so  that  the  pulse  is  quickened  in  a 
twofold  fashion. 

Effect  of  Heat  and  Cold  on  Pulmonary 
Capillaries. — I  have  found  that  if  a  stream  of 
warm  moist  air  be  first  directed  on  the  lung  of 
a  frog,  and  immediately  afterwards  a  stream 
of  cold  moist  air,  the  capillaries  sometimes 
contract  as  much  as  one-third  of  their  diameter 
under  the  influence  of  the  cold.39  This  reaction 
may  explain  the  feeling  of  constriction  in  the 
chest  which  sometimes  comes  on  when  passing 
from  a  warm  room  into  cold  air,  and  also  the 
action  of  a  wind  in  the  face,  causing  angina 
pectoris. 

Blood-pressure.  Schema. — A  very  simple 
schema  of  the  circulation  which  is  useful  in 
obtaining  a  thorough  comprehension  of  its 
mechanism  can  easily  be  made  by  anyone. 
It  consists  of  an  india-rubber  ball  representing 
a  heart,  an  elastic  bulb  representing  the  arteries, 
a  soft-walled  bag  representing  the  veins.  By 
connecting  this  with  a  mercurial  manometer, 
such  as  that  of  an  ordinary  sphygmomanometer, 
the  comparative  effects  of  the  heart  and  vessels 
upon  the  pressure  in  the  arterial  system  can  be 
readily  observed.  The  soft-walled  bag,  or  veins, 
can  contain  all  the  fluid  in  the  whole  vascular 
system,  or  even  more.  In  using  this  schema  we 
commence  with  the  pressure  at  zero,  and  slowly 


BLOOD-PRESSURE— KYMOGRAPHS       95 

compress  the  india-rubber  ball,  representing  the 
heart.  As  it  is  emptied  it  drives  the  fluid  into 
the  elastic  bulb,  or  arterial  system.  If  the 
passage  is  left  open  into  the  venous  bag,  the 
mercurial  column  oscillates  with  each  pulse, 
rising  as  the  fluid  is  driven  in,  and  sinking 


Fio.  27. — Simple  schema  of  the  circulation.  It  consists  of  a  spray, 
producer,  bladder,  and  mercurial  manometer.  The  elastic  ball  of  the 
spray-producer  represents  the  heart,  the  elastic  bag,  covered  with 
netting  to  prevent  too  great  distension,  represents  the  aorta  and 
arterial  system,  and  the  bladder  represents  the  venous  system. 

again  in  the  interval.  But  if  the  stopcock  is 
turned  so  as  to  prevent  all  the  fluid  driven  in 
at  each  pulsation  from  going  into  the  veins,  the 
pressure  will  gradually  rise  in  the  bulb  until  it 
is  sufficient  to  drive  out  during  the  diastole  all 
the  fluid  sent  in  during  the  systole. 

Kymographs. — The  pressure  is  measured  in 
animals  by  putting  a  cannula  into  an  artery  and 
connecting  it  with  a  mercurial  manometer.40  In 


96  PHYSIOLOGY  OF  VESSELS 

order  to  prevent  coagulation,  the  tube  leading 
from  the  artery  to  the  manometer  is  filled  either 
with  some  saline  solution  or  solution  of  pep- 
tone,41 which  hinders  coagulation,  or  leech- 
extract  (hirudin)42  is  injected.  The  oscillations 
of  the  mercurial  column  are  recorded  on  a 
revolving  cylinder,  and  the  whole  instrument, 
consisting  of  mercurial  manometer  and  record- 
ing cylinder,  is  called  Lud wig's  kymograph. 

In  order  to  avoid  the  intrinsic  oscillations  of 
a  mercurial  column  other  recording  instruments 
have  been  employed,  such  as  the  spring  man- 
ometer of  Pick,  in  which  the  tension  causes  a 
curved  tube  to  straighten  or  bend,  or  the  man- 
ometers of  Hiirthle  or  Roy,  where  the  oscillations 
are  very  small,  but  are  much  magnified  by  the 
recording  lever. 

Blood -pressure  in  Animals. — The  average 
blood-pressure  in  animals  varies  according  to 
their  size,  but  not  to  the  extent  that  we  should 
imagine.  In  a  horse  it  has  been  found  to  be 
roughly  between  200  and  300  mm.,  in  a  dog  140 
to  170,  in  a  sheep  150  to  i/o.43 

Blood-pressure  in  Man. —  In  man  it  has  been 
found  to  be  from  100  to  160,  in  cases  where  it 
was  estimated  in  a  limb  before  amputation.44 


LITERATURE. 

1  Verhandl.  d.  Med.  Phys.  Gesellsch.^  Wurzburg,   1854, 

j>.  I,  quoted  in  Schmidt's  Jahrb.^  vol.  Ixxxv.,  p.  12. 

2  "Etudes   de   1'Innervation   du   Cceur,  etc.,"  par  J.  F. 

Heymans  and  L.  Demoor,  Memoires  Coronnh  Acad. 


LITERATURE  OF  CHAPTER  IV  97 

Roy.  de  Med.  de  Belgique,  1894,  vol.  xiii.,  pi.  xviii., 

fig-  34- 

3  Vide  Tigerstedt,  Lehrb.  d.  Physiol.  d.  KreisL,  p.  512 

(Leipzig  :  Veit  &  Co.,  1893). 

4  Strieker,  Sitzungsb.  d.  k.  Akad.  d.    Wiss.  Math.  Nat. 

Cl.,  1865,  vol.  xli.,  Abt.  2-3  ;  1866,  vol.  li. ;  1876, 
vol.  Ixxiii.,  Abt.  3,  p.  316. 

6  Lauder  Brunton,  Ludwigs  Arbeiten,  4'"  Jahrg. ;  and 
Collected  Papers  on  Circulation,  First  Series, 
pp.  1 60,  178. 

6  Mall,  Ludwigs  Arbeiten,  1890. 

7  Thompson,  Arch.  f.  Anat.  u.  Physiol.,  1893,  p.  102  ; 

Bancroft,  Arner.  Journ.  of  Physiol.,  1898,  vol.  i.,  p.  477. 

8  Russell  Wells  and  Leonard  Hill,  Proc.  Roy.  Soc.,  1913, 

p.  192. 

9  Wharton  Jones,  Phil.  Trans.,  1852,  p.  131. 

10  Schiff,  Arch.f.  Physiol.  Heilk.,  1854,  vol.  xiii.,  p.  523. 

11  Vulpian,    Compt.   rend.   d.    Soc.   Biol.,   1856,   vol.  iii., 

p.  183  ;  1858,  p.  3. 
2  Schiff,  Arch.f.  Physiol.  Heilk.,  1854,  vol.  xiii.,  p.  524. 

13  Lauder  Brunton,  Ludwigs  Arbeiten,  4ter  Jahrg.,  1869, 

p.  1 06. 

14  Lauder  Brunton,  Journ.  of  Physiol.,  1884,  vol.  v.,  p.  14. 

15  Douglas  Cow,  Journ.  of  Physiol.,  1911,  vol.  xiii.,  p.  141. 

16  Ninian  Bruce,  Arch.  f.  exp.  Path.   ic.  Pharm.,  1910, 

vol.  Ixiii.,  p.  424. 

17  Claude  Bernard,  Leqons  de  Physiologic  exp.,  vol.  i., 

p.  31  et seq.  (Paris,  1855). 

18  A   very  complete  account,  with  full  bibliography,  is 

given  by  Swale  Vincent,  Ergebnisse  d.  Physiol., 
9  Jahrg.,  1910^.451  etseq.  (Weisbaden  :  Bergmann). 

19  Lander  Brunton,  St  Bartholomew's  Hospital  Journal, 

December  1897. 

20  Oliver  and  Schafer,  Journ.  of  Physiol.,  1895,  vol.  xviii., 

p.  278  ;  Howell,  Journ.  of  Exp.  Med.,  1898,  vol.  iii., 
p.  241;  et  seq.;  Schafer  and  Herring,  Phil.  Trans., 
1906,  B.,  vol.  cxcix.,  p.  27. 

21  Ehrmann,   Arch.   f.   exper.   Path.    u.    Pharm.,    1905, 

vol.  liii.,  p.  1 10  ;  Strehl  and  Weiss,  Pfliiger's  Archiv, 
1901,  vol  Ixxxvi.,  p.  107. 

22  Cf.  Oliver  and  Schafer,  Journ.  of  Physiol.,  1895,  vol. 

xviii.,  p.  269  ;  gives  literature  also. 


98  LITERATURE 

23  Gibson,  Brit.  Med.  Journ.,  27th  July  1912,  p.  167. 

24  Oliver  and  Schafer,  Journ.  of  Physiol ,  1895,  vol.  xviii., 

P.-  239- 

26  Oliver  and  Schafer,  op.  tit.,  vol.  xviii.,  p.  277  ;  W.  H. 
Howell,  Journ.  of  Exp.  Med.,  1898,  vol.  iii.,  p.  245 
et  seq.;  Schafer,  Proc.  Roy.  Sac.,  1909,  B.,  vol.  Ixxxi., 
p.  442  et  seq.,  with  bibliography. 

26  Dixon  and  Dale,  Brit.  Med.  Journ.,  7th  August  1909, 

vol.  ii.,  p.  329;  and  Journ.  of  Physiol.,  1909,  vol. 
xxxix.,  p.  25. 

27  Barger  and  Walpole,  Journ.  of  Physiol. ,   1909,  vol. 

xxxviii.,  p.  350. 

28  Brown-Se"quard,  Compt.  rend.,  1892;  Brown-Sdquard 

and  d'Arsonval,  Compt.  rend.,  1892,  torn.  114,  p.  1399, 
and  Arch,  de  Physiol.,  1893,  p.  200 ;  E.  Meyer, 
Arch,  de  Physiol.,  1893,  p.  761,  and  ibid.,  1894, 
p.  179  ;  Tigerstedt  and  Bergmann,  Trans,  of  XI  1th 
Congress  of  Medicine,  Moscow,  1897,  section  of 
Physiology,  p.  24. 

29  Bunge    and    Schmiedeberg,   Arch.  f.  exp.   Path.   u. 

Pharm.,  vol.  vi.,  p.  233  ;  Schmiedeberg,  ibid.,  vol. 
*iv.,  p.  379- 

30  Cromaine,  Recherches  exp.  s.  I.  secretion  interne  des 

reins,   Thesis   (Nancy,    1902) ;  quoted    by   Parisot, 
Secretion  interne  et  pression  arterielle,  p.  295  (Paris, 
1908). 
51  Parisot,  op.  ctt.,  p.  298. 

32  Parisot,  op.  cit.,  p.  302. 

33  J.  Rose  Bradford,  Allbutfs  System  of  Medicine,   1st 

ed.,  vol.  iii.,  p.  335  ;  2nd  ed.,  1908,  vol.  iv.,  part  i, 

P-  583- 

34  Geo.  Johnson,  Brit.  Med.  fourn.,  1873,  vol.  i.,  p.  59. 

36  Gull  and  Sutton,  Trans.   Path.  Soc.,  London,   1877, 

p.  361. 

16  Rjckett,  fourn.  of  Path,  and  Bacteriology,  1908, 
vol.  xii.,  p.  15  et  seq. 

37  Lauder  Brunton,  £/  Bartholomew's  Hospital  Reports, 

1871,  vol.  vii.,  p.2\6etsef.;  and  Collected  Papers,  First 
Series,  p.  204.  The  earlier  literature  is  here  given. 

38  Gaskell,  Phil.  Trans.,  1882,  p.  993. 

39  Lauder    Brunton,    Brit.   Med.  fourn.,    1875,  vol.   i., 

p.  201  ;  and  Collected  Papers,  First  Series,  p.  333. 


LITERATURE  OF  CHAPTER  IV  99 

40  The  technique  is  described  in  my  Collected  Papers, 

First  Series,  p.  279  et  seq. 

41  Schmidt-Miihlheim,  Arch.f.  Anat.  u.  PhysioL,  Leipzig, 

1880,  p.  33  ;  and  Ludivig's  Arbeiten  for  1880,  p.  50. 

42  Haycraft,  Proc.  Roy.  Soc.y  1884,  vol.  xxxvi.,  p.  478. 

43  Tigerstedt,  Lehrb.  d.  Phys.  d.  KreisL,  p.  328. 

44  Faivre,  and  also  Albert,  quoted  by  Tigerstedt,  op.  cit., 

P- 329- 


CHAPTER   V 

EXAMINATION   OF  BLOOD-PRESSURE   IN    MAN 

Measurement  of  Blood-pressure  in  Man — Instruments — 
Sphygmomanometers  —  Bulb  forms  —  Band  forms 
— Standardisation  of  Aneroids — Method  of  using 
Bulb  Sphygmomanometers — Fallacies — Use  of  Band 
Sphygmomanometers — Fallacies — Systolic  Pressure 
— Effect  of  Food — Effects  of  Exercise — Effect  of 
Emotion  —  Diastolic  Pressure  —  Measurement  of 
Diastolic  Pressure  —  Instruments  —  Relations  of 
Systolic  to  Diastolic  Pressure — Pulse  Pressure — 
Significance  of  Pulse  Pressure — Size  of  Vessels — 
Measurement  of  Pressure  in  Veins — Measurement  of 
Pressure  in  Capillaries. 

Measurement  of  the  Blood-pressure  in  Man. 

— It  is  naturally  of  very  great  importance  that 
we  should  be  able  to  estimate  the  pressure  in 
man  without  opening  an  artery,  and  numerous 
instruments  have  been  devised  for  this  purpose. 
By  simply  feeling  the  pulse  with  a  finger,  one 
can  roughly  make  out  whether  the  pressure 
within  it  is  high  or  low,  and  this  is  still  better 
done  by  placing  three  fingers  upon  the  pulse 
and  compressing  it  with  the  one  nearest  the 
heart,  and  noticing  with  the  middle  one  when  it 

ceases   to   beat.     By   the   amount    of  pressure 
100 


SPHYGMOMANOMETERS  101 

exercised  one  can  form  some  judgment  regard- 
ing the  tension,  but  it  is  evident  that  one  cannot 
convey  any  quantitative  knowledge  regarding 
the  pulse  felt  this  way  to  another.  The  third 
ringer  nearest  the  hand  compresses  the  artery 
so  as  to  obstruct  the  recurrent  pulse  from  blood 
flowing  through  the  ulnar  artery  and  palmar 
arch. 

Instruments. 

The  first  man  to  invent  a  practical  sphygmo- 
manometer  for  clinical  use  was  von  Basch. 
Instead  of  compressing  an  artery  by  a  finger 
alone,  he  placed  beneath  the  finger  a  caoutchouc 
bulb  filled  with  air,  and  connected  with  an 
aneroid  manometer  in  which  the  amount  of 
compression  could  be  read  off.  He  showed  that 
this  instrument  correctly  indicated  the  pressure 
within  the  compressed  vessel,  by  connecting  one 
femoral  artery  of  a  dog  with  a  mercurial  man- 
ometer and  compressing  the  other  by  an  elastic 
bulb.  When  the  pressure  inside  the  bulb  was 
gradually  raised  it  was  found  that  the  pressure 
which  stopped  pulsation  in  the  distal  part  of  the 
artery  was  the  same  as  that  indicated  within  the 
other  artery  by  the  manometer.1 

Sphygmomanometers.  —  These  may  be 
roughly  divided  into  two  classes.  Those  that 
compress  a  single  artery  and  those  which  com- 
press a  digit  or  limb.  Those  which  compress  a 
single  artery  consist  of  an  india-rubber  bulb 
connected  with  a  measuring  apparatus  like  that 
of  von  Basch.  The  best  known  of  them  are 


102    EXAMINATION  OF  BLOOD-PRESSURE 

von  Basch's,2  Potam's,3  Oliver's,4  Hill's,5  and 
Sahli's.6  The  advantage  of  these  instruments  is 
that  they  can  be  applied  quickly  and  easily,  so 
that  in  cases  of  nervous  and  troublesome  patients 
they  can  be  used  when  a  band  instrument  would 
not  be  tolerated.  Their  disadvantage  is  that 
unless  they  are  most  carefully  applied  they  are 
less  accurate.  Different  observers  using  the 
same  instrument  may  obtain  readings  differing 
as  much  as  20  mm.  or  even  more,  so  that  when  a 
really  accurate  estimate  is  required  in  a  patient 
I  think  a  band  instrument  should  be  used. 

Bulb  Sphygmomanometers.  —  Von  Basch's 
consists  of  an  india-rubber  bulb  filled  with  air, 
and  communicating  with  a  manometer,  mercurial 
or  aneroid.  The  bulb  is  placed  over  an  artery, 
generally  the  radial,  and  pressed  down  on  the 
artery  till  the  pulse  beyond  can  no  longer  be 
felt.  The  pressure  required  to  stop  the  pulse  is 
then  read  off  on  this  manometer.  Potain's 
instrument  differs  from  von  Basch's  only  in  the 
bulb  having  thinner  rubber  on  the  side  to  be 
laid  on  the  artery,  and  thicker  rubber  on  the 
other  sides. 

Oliver's  first  sphygmometer  consists  of  a  bulb 
filled,  not  with  air  but  with  glycerine.  On  this 
a  rod  rests,  which  communicates  the  pressure  by 
means  of  a  spring  to  an  index  moving  on  a  dial. 
Leonard  Hill's  consists  of  a  small,  very  flat 
funnel  with  a  graduated  stem.  The  wide  end 
of  the  funnel  is  closed  by  a  membrane  and  the 
small  end  by  a  stopcock.  In  this  is  a  coloured 
fluid,  which  works  against  the  resistance  of  the 
enclosed  air.  Sahli's  is  like  von  Basch's,  but 


BULB  AND  BAND  INSTRUMENTS       103 

has  a  larger  bulb  and  a  very  portable  mercurial 
manometer. 

Band  Sphygmomanometers.  —  The  second 
class  of  sphygmomanometers  are  those  which 
compress  the  arm  or  finger.  Gaertner's  ton- 
ometer, which  compresses  the  finger,  is  much 
used  in  Germany,  but  is  not  often  employed  in 
this  country.7 

It  consists  of  a  metal  ring  (A,  Fig.  28)  1-5  cm. 
broad,  to  the  inside  ofwhich  an  india-rubber  mem- 
brane is  fixed,  so  as  to  leave  an  air  space  between 
it  and  the  ring.  This  space  communicates  by  an 
opening  in  the  side  of  the  ring,  and  a  T-tube 
with  a  manometer  and  a  pressure-ball.  The 
ring  is  placed  loosely  on  the  middle  phalanx  of 
one  finger,  and  the  blood  pressed  out  of  the 
last  phalanx,  either  by  rolling  a  thick,  narrow 
india-rubber  ring  upwards,  or  by  wrapping  a 
piece  of  fine  india-rubber  tubing  tightly  round 
the  finger  from  its  tip  upwards  (B,  Fig.  28).  The 
pressure  is  then  raised  in  the  apparatus  to  a  point 
which  is  certain  to  be  above  the  pressure  in  the 
arteries,  e.g.  200  mm.  of  mercury.  The  india- 
rubber  ring  is  then  rolled  off  or  the  tube 
unwound,  leaving  the  last  phalanx  white  and 
bloodless.  The  pressure  is  then  lessened  and 
the  finger-tip  watched,  so  as  carefully  to  note 
when  it  begins  to  flush  with  the  returning 
circulation.  The  height  of  the  mercurial  column 
*t  this  moment  indicates  the  systolic  pressure  in 
the  digital  arteries. 

The  instruments  which  compress  the  arm 
consist  of  a  flat  india-rubber  bag,  the  outside  of 
which  is  covered  with  some  unyielding  substance, 


104    EXAMINATION  OF  BLOOD-PRESSURE 

and  is  connected  both  with  a  bulb,  which  can  be 
used  to  inflate  it,  and  with  a  measuring  apparatus, 
which  may  be  either  a  mercurial  column  or  an 
aneroid.  This  bag  is  strapped  on  the  arm  and 


FIG.  28.— Gaertncr's  portable  tonometer ;  A  is  a  metal  ring  with  india- 
rubber  membrane  inside.  B  is  a  piece  of  india-rubber  tubing  wound 
round  the  end  of  the  finger  so  as  to  drive  all  the  blood  out  of  it.  T  is 
a  tube  communicating  with  a  pressure-bulb. 

gradually  inflated  until  the  pressure  is  sufficient 
to  stop  the  pulse  at  the  wrist  The  pressure  is 
then  read  off  on  the  mercurial  column  or  the 
aneroid.  This  method  was  introduced  indepen- 
dently by  Riva  Rocci,8  and  by  Hill  and  Barnard.9 


ANEROID  AND  MERCURIAL 


105 


I  think  the  best  single  instrument  for  applying 
it  is  Martin's  non-spillable  mercurial  sphygmo- 
manometer.10  An  aneroid  can  also  be  used 
with  this  bag,  and  is  more  convenient  for  carry- 
ing about,  as  the  aneroid,  the  bulb  to  increase 
the  pressure,  and  the  armlet  can  all  be  con- 
veniently carried  in  the  pocket.11  By  the 
arrangement  shown  in  Fig.  29  either  a  bulb 


FIG.  29. — Author's  apparatus  for  using  a  broad  Biva-Rocci  band  with  von 
Basch's  or  Potain'a  sphygmomanometer  instead  of  a  mercurial 
manometer.  .  ..  • 

or  an  armlet  can  be  used  at  pleasure.  The 
disadvantage  of  the  aneroid  is  that  it  is  apt  to 
vary  from  time  to  time,  and  requires  to  be 
compared  once  in  two  or  three  weeks,  or  even 
oftener,  with  a  mercurial  manometer  to  ascer- 
tain the  true  reading.  It  is,  therefore,  always 
necessary  to  have  a  mercurial  manometer  as 
well  (Fig.  30). 


106    EXAMINATION  OF  BLOOD-PRESSURE 

Standardisation  of  Aneroids.  —  This  can 
easily  be  done  in  less  than  two  minutes  by  the 
arrangement  shown  in  Fig.  30. 

In  the  first  edition  of  this  book  I  described 
and  figured  a  large  number  of  instruments  for 


FIG.  80. — Author's  apparatus  for  ascertaining  the  correctness,  or  amount 
of  error  in  an  aneroid  sphygmomanometer.  By  means  of  a  three-way 
stopcock,  both  the  aneroid  and  a  mercurial  manometer  are  put  into 
communication  with  a  pressure-bulb  of  a  spray  apparatus.  The 

•  pressure  is  then  raised  5  mm.  at  a  time,  and  the  readings  of  the 
mercurial  and  aneroid  compared  at  each  pressure  show  the  amount 
of  variation  between  them  and  the  corrections  necessary  in  the 
readings  of  the  aneroid. 

taking  blood-pressure,  but  the  measurement  of 
blood-pressure  has  become  so  common  now  that 
it  is  almost  unnecessary  to  mention  more  than 
one  or  two,  as  I  have  done.  Other  sphygmo- 
manometers  have  also  been  described  byjaneway 
in  his  Clinical  Study  of  Blood  Pressure^ 


METHODS  OF  USE— FALLACIES        107 

Method  of  using  Sphygmomanometers. —  In 
using  a  bulb  apparatus,  such  as  von  Basch's  or 
Potain's,  the  bulb  is  simply  placed  on  the  radial 
artery  as  it  passes  over  the  radius  and  com- 
pressed with  the  index  finger,  while  the  pulse 
nearer  the  hand  is  felt  with  the  middle  finger. 
The  bulb  is  then  pressed  until  the  pulse  ceases 
to  be  felt,  and  the  pressure  is  read  off  on  the 
index.  Instead  of  using  two  fingers  of  the  same 
hand  it  is  better  to  compress  the  bulb  with  the 
finger  of  one  hand  and  to  feel  the  pulse  with  the 
finger  of  another,  while  the  artery  beyond  can 
be  compressed  with  a  third  finger.  When  the 
bulb  consists  of  different  thicknesses  of  india- 
rubber,  the  thicker  part  ought  to  be  placed 
outside  and  the  thinner  part  next  the  artery. 
The  hand  should  be  kept  at  the  level  of  the  heart. 

Fallacies  in  using  Bulb  Instruments. — Un- 
less the  elastic  bulb  is  placed  over  the  end  of 
the  radius  so  that  the  arteries  can  be  compressed 
between  it  and  the  bulb,  and  not  over  the  soft 
tissues,  too  high  a  reading  is  obtained.  If  the 
palmar  arch  is  dilated  the  recurrent  pulse 
through  it  from  the  ulnar  arteries  may  cause 
the  pulse  to  be  felt  after  the  radial  has  been 
completely  compressed  by  the  bulb.  To  avoid 
this,  the  palpating  finger  should  be  placed  on 
the  radial  artery  with  the  tip  pointing  upwards. 
Any  recurrent  pulse  is  then  stopped  by  the 
pulp  of  the  finger,  and  the  central  radial  pulse  is 
felt  by  the  finger-tip.  Instead  of  this,  two 
fingers  may  be  used,  as  already  mentioned. 

Armlet  Sphygmomanometers.  —  In  using 
these,  the  armlet  is  fastened  round  the  arm  and 


io8    EXAMINATION  OF  BLOOD-PRESSURE 

inflated  by  a  small  india-rubber  hand-pump 
until  the  pressure  is  sufficiently  great  to  stop 
the  pulse.  This  point  is  noted,  and  the  pressure 
is  then  increased  a  little  further;  air  is  then 
gradually  let  out,  and  the  pressure  is  again 
noted  when  the  pulse  begins  to  reappear.  In 
this  way  one  has  actually  two  observations 
made  close  together  of  the  pressure  which  stops 
the  flow  of  blood  in  the  artery. 

In  a  number  of  observations  which  I  have 
made  it  has  appeared  to  me  that  one  sometimes 
gets  a  difference  of  5  mm.  between  the  values 
obtained  when  raising  the  pressure  and  that 
obtained  with  a  falling  pressure,  the  former 
being  the  higher. 

Fallacies  of  the  Armlet  Sphygmomanom- 
eter. — The  original  armlet  of  Riva  Rocci  was 
too  narrow  and  gave  too  high  a  reading,  but 
with  the  armlets  now  commonly  used  not  less 
than  12  centimetres  or  5  inches  broad,  as  recom- 
mended by  von  Recklinghausen,13  the  reading  is 
generally  correct. 

There  has  been  a  good  deal  of  discussion 
regarding  the  effect  of  rigidity  of  the  arteries 
upon  the  values  obtained  by  the  armlet 
sphygmomanometer.14  As  a  rule,  the  effect  of 
somewhat  rigid  arteries  is  not  very  great,  but 
whenever  the  vessels  are  felt  to  be  rather  rigid 
it  is  advisable  to  apply  the  instrument  not  to 
one  arm  only,  but  to  both  arms,  or  even  to  the 
forearm  as  well.  The  rigidity  of  the  arteries, 
as  a  rule,  does  not  affect  all  the  vessels  equally, 
and  if  different  values  are  obtained  the  lowest 
should  be  selected. 


S  YSTOLTC  PRESS VRE  109 

Though  the  rigidity  of  stiff  arteries  does  not 
as  a  rule  greatly  affect  the  values  obtained  by 
the  sphygmomanometer,  yet  if  the  artery  is  in  a 
state  of  contraction  it  opposes  more  resistance 
to  compression,  and  the  reading  may  therefore 
be  too  high.15 

It  has  seemed  to  me  that  in  very  muscular  or 
very  fat  limbs  the  reading  of  the  band  instru- 
ment is  too  high,  and  ought  not  to  be  accepted 
at  once,  but  should  be  compared  with  readings 
obtained  by  a  bulb  instrument  on  the  radial 
artery,  which  is  simply  covered  by  skin,  so  that 
the  muscle  cannot  interfere.  As  a  possible 
source  of  error  this  seems  to  me  to  have 
received  little  attention. 

Systolic  Pressure. — The  pressure  at  which 
the  pulse  is  obliterated  by  the  sphygmomanom- 
eter indicates  the  systolic  pressure  or  maximum 
height  to  which  the  tension  within  the  artery  is 
raised  by  the  wave  of  blood  driven  into  the 
aorta  by  the  heart.  In  cases  where  the  pulse  is 
very  irregular  the  highest  pressure  may  only  be 
noted  with  every  third,  fourth,  or  fifth  beat,  or 
even  seldomer, 

According  to  my  own  observations  made  in 
the  sitting  posture  with  a  broad  armlet,  I  find 
that  from  8  to  14  years  of  age  the  maximum 
pressure  is  about  90  mm.  From  1 5  to  20  years 
it  is  about  100  to  1 1 5  or  1 20  mm.  From  21  to  65 
years  of  age  it  is  from  120  to  135  or  150  mm., 
the  common  pressure  being  125  or  130  mm. 
Above  65  years,  if  the  arteries  are  elastic,  the 
pressure  may  still  remain  135  to  150.  If  the 
arteries  are  rigid,  it  may  go  up  to  iSoor  200  mm. 


no    EXAMINATION  OF  BLOOD-PRESSURE 

or  even  higher.  In  women  the  pressure  is  as  a 
rule  10  or  15  mm.  lower  than  the  corresponding 
pressure  in  men,  and  in  strong  athletic  men  it 
may  be  15  mm.  above  the  average.  Though 
these  values  may  not  absolutely  coincide  with 
those  of  other  observers,  I  think  they  are  very 
nearly  the  truth.16 

Some  observations  I  have  made  on  natives 
of  India  have  yielded  lower,  and  some  on 
Canadians  have  yielded  higher  pressures  than 
these. 

Effect  of  Pood  on  Blood  -  pressure. —  Food 
usually  raises  the  blood-pressure  and  quickens 
the  pulse,  but  the  effect  depends  much  on  its 
quantity,  quality,  and  temperature.  Much  hot 
food  or  hot  liquid  put  into  the  stomach  will 
stimulate  the  heart,  which  rests  on  the  stomach 
with  only  the  diaphragm  between,  and  thus  tend 
to  raise  the  pressure  ;  but  the  warmer  blood  will 
cause  the  vessels  to  dilate,  and  the  ultimate 
result  as  regards  blood-pressure  will  depend  on 
the  preponderance  of  one  or  other  of  these 
factors.  If  they  be  nearly  equal  the  pressure 
may  remain  unchanged  though  the  pulse  may 
be  quicker.17 

Effect  of  Exercise  on  Blood-pressure. — The 
effect  of  exercise  differs  according  to  its  amount 
and  duration,  the  time  of  day,  and  condition  of 
the  body.  In  exercise  of  any  kind  numerous 
muscles  contract  either  simultaneously  or  suc- 
cessively. Each  muscle  as  it  contracts  presses 
on  the  blood-vessels  within  it  and  drives  the 
blood  out  with  a  spurt18  But  during  its  con- 
traction the  arteries  supplying  it  dilate,19  and 


AGENCIES  AFFECTING  BLOOD-PRESSURE  1 1 1 


thus  the  blood  flows  more  freely  through  it, 
unless  it  presses  so  much  on  the  arteries  as  to 
lessen  or  even  stop  the  flow  through  them.  But 
when  the  contraction  ceases  and  the  pressure 
on  the  arteries  is  thus  removed,  the  blood  pours 
through  them.20  If  the  exertion  requires  such 


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Fio.  31. — Effect  of  exercise  on  pulse  and  blood-pressure.    (Brunton  and 
Tnnnicliffe.) 

strong  muscular  contraction  as  to  stop  the  flow 
through  them  during  its  continuance,  it  is 
obvious  that  the  tension  must  almost  of  necessity 
rise  considerably  or  even  greatly,  and  this  is  what 
does  occur. 

Even  moderate  exercise  tends  to  raise  the 
tension    at   first.     But   as   the   arteries   of  the 


112    EXAMINATION  OF  BLOOD-PRESSURE 

muscles  dilate,  the  tension  falls  even  during  the 
continuance  of  the  exercise  and  continues  to 
fall  for  some  time  afterwards.  This  is  well 
shown  in  the  accompanying  curve,  which  re- 
presents the  results  obtained  by  Dr  Tunnicliffe 
and  myself  in  some  experiments  on  this  subject 

(Fig.  3 1)-21 

Potain  found  that  the  effect  of  exercise  varied 
according  to  the  time  of  day  and  condition  of 
the  person.  When  taken  in  the  morning,  fasting, 
it  almost  always  lowered  the  tension  ;  but  when 
taken  in  the  afternoon,  three  hours  after  a  meal, 
it  generally  increased  the  tension.22 

Effect  of  Emotion.  —  The  effect  of  emotion 
may  be  very  great.  In  1903  I  had  arranged  with 
Professor  Kronecker  to  make  some  observations 
on  the  blood-pressure  in  workmen  in  the  Jung- 
frau  tunnel,  where  we  were  to  meet  each  other. 
When  I  reached  the  station  at  Grindelwald  I 
found  the  train  quite  full,  so  that  all  chance  of 
meeting  my  friend,  who  was  to  come  from  Lauter- 
brunnen,  seemed  to  be  gone.  I  was  greatly 
annoyed,  but  could  do  nothing  to  help  it,  and  so 
I  sat  down  and  took  my  own  blood-pressure.  To 
my  astonishment  I  found  it  had  gone  up  from 
1 20  mm.,  which  was  my  normal,  to  160  mm., 
the  increase  amounting  to  no  less  than  one-third 
of  my  normal.  I  had  only  walked  a  few  steps 
slowly  before  taking  the  pressure,  so  that  there 
was  nothing  but  the  emotion  to  cause  the  rise. 

Diastolic  Pressure.  —  Diastolic  pressure  is 
the  minimum  to  which  the  blood-pressure  sinks 
during  the  interval  between  the  cardiac  beats, 
when  no  blood  is  coming  into  the  aorta  from 


DIASTOLIC  PRESSURE  11.3 

the  heart,  and  the  arterial  system  is  emptying 
itself  through  the  capillaries  into  the  veins. 
It  varies,  therefore,  with  the  length  of  that 
interval,  and  with  the  strength  of  the  heart, 
the  amount  of  blood  sent  into  the  aorta  at 
each  systole,  and  the  patency  of  the  capillaries. 
In  a  general  way,  just  as  the  systolic  pressure 
depends  greatly  on  the  strength  of  the  heart, 
so  the  diastolic  depends  on  the  degree  of 
contraction  or  relaxation  of  the  capillaries. 

Measurement  of  Diastolic  Pressure.  —  An 
easy  method  of  ascertaining  the  diastolic  blood- 
pressure  clinically  is  by  auscultation.  This 
appears  to  have  been  first  used  by  Korotkow.23 
A  stethoscope  is  placed,  or  a  small  phonendo- 
scope  is  tied  over  the  brachial  artery  below  the 
armlet.  When  there  is  no  pressure  no  cardiac 
sound  is  heard,  but  as  the  pressure  is  raised  a 
"thud,  thud"  usually  makes  its  appearance  quite 
sharply.  This  continues  until  the  maximum 
pressure  is  reached,  when  it  stops  abruptly.  On 
again  lowering  the  pressure,  the  "  thud,  thud " 
reappears  and  continues  until  a  lower  point  is 
again  reached  when  it  ceases  to  be  heard.  The 
disappearance  of  the  sounds  at  the  higher  level 
usually  coincides  very  nearly  with  the  systolic 
pressure  as  obtained  by  palpation  of  the  radial 
artery.  The  appearance  of  the  sounds  at  the 
lower  level  with  the  rising  pressure,  or  their 
disappearance  with  a  falling  pressure,  indicates 
the  diastolic  pressure.  According  to  Oliver, 
the  range  of  pressure  over  which  the  sounds  are 
heard  becomes  shorter  and  the  sounds  feebler 
when  the  heart  is  weak.24 


H4    EXAMINATION  OF  BLOOD-PRESSURE 

Another  method  of  ascertaining  the  diastolic 
pressure  is  by  observing  the  amount  of  oscilla- 
tion that  occurs  in  the  walls  of  the  artery  at 
each  pulse.  Marey  and  Mosso  found  that  this 
is  at  its  maximum  when  the  pressure  inside 
and  outside  the  artery  is  nearly  equal.25  By 
practice  some  people  can  distinguish  by  the 
finger  alone  when  the  radial  pulse  is  largest, 
and  thus  ascertain  the  diastolic  pressure.  For 
this  purpose  the  pulp  of  the  last  phalanx  and 
not  the  finger-tip  should  be  placed  on  the 
artery,  and  the  observation  repeated  several 
times,  raising  and  lowering  the  pressure  in 
the  armlet. 

Instruments  for  ascertaining  Diastolic  Pres- 
sure.— Oscillations  can  be  seen  in  an  ordinary 
sphygmomanometer,  mercurial  or  aneroid,  but 
they  can  be  observed  more  easily  when  they 
are  more  extensive.  This  is  the  case  in  Oliver's 
sphygmometers,  both  old  and  new,  especially 
in  the  latter,  which  has  a  coloured  fluid  index 
working  against  a  column  of  compressed  air.26 
The  scale  is  long,  and  the  amount  of  oscillation 
is  easily  noted.  The  pressure  can  be  alter- 
nately raised  and  lowered  with  great  exactitude 
by  means  of  a  bag  containing  air,  and  placed 
in  a  kind  of  screw  clamp. 

In  Sahli's  sphygmobolometer  the  oscillations 
are  shown  in  a  similar  way,  but  the  actual 
pressure  is  shown  by  a  second  mercurial  column 
which  is  also  connected  to  the  armlet,  and  is 
contracted  at  one  point  so  as  to  prevent  oscilla- 
tions in  it.27 

Von    Recklinghausen's  ^    instrument    is    an 


P  ULSE-PRESSURE  1 1 5 

aneroid  with  a  long  index  and  large  disc, 
so  as  to  give  amplitude  to  the  oscillation. 
Pachon's29  oscillometer  consists  of  two  aneroids, 
one  within  the  other.  The  outer  has  a  disc 
showing  the  pressure.  When  the  inner  is  con- 
nected with  the  outer  so  that  the  pressure  in 
both  is  alike,  the  long  index  which  works  on 
a  large  disc  does  not  oscillate,  but  when  the 
communication  is  stopped  the  index  of  the 
inner  manometer  makes  large  oscillations. 

To  measure  the  extent  of  oscillation  exactly 
with  any  of  these  instruments  is  not  always 
easy,  but  when  the  oscillations  are  recorded 
on  paper  as  they  are  by  Erlanger's,30  Hirsch- 
felder's,31  or  Gibson's32  recording  sphygmoman- 
ometer,  the  oscillations  can  be  measured  with 
compasses  and  their  exact  size  determined. 

Relation  of  Systolic  to  Diastolic  Tension. 
Pulse-pressure. — The  name  pulse-pressure  has 
been  applied  to  the  oscillation  or  difference 
between  the  systolic  and  diastolic  tensions.  Its 
use  is  to  indicate  the  strength  of  the  heart  in 
relation  to  the  resistance  it  has  to  overcome. 

Strassburger  ^  and  Janeway34  estimate  the 
pulse  -  pressure  as  being  ordinarily  equal  to 
one -fourth  of  the  systolic  pressure.  But  this 
relationship  may  vary  considerably.  When  the 
pulse  is  slow  there  is  more  time  for  the  blood 
to  run  out  from  the  arteries  into  the  veins 
in  the  interval  between  the  beats  of  the  heart, 
and  so  the  oscillation  of  tension,  or  difference 
between  the  systolic  and  diastolic  pressures, 
is  greatly  increased.  On  the  other  hand, 
when  the  pulse  is  quick  there  is  little  time 


n6    EXAMINATION  OF  BLOOD-PRESSURE 

for  the  blood  to  flow  out,  and  so  the  difference 
between  the  systolic  and  diastolic  is  small.  In 
addition  to  this,  when  the  pulse  is  slow  there  is 
more  time  for  the  heart  to  fill  completely,  and 
the  amount  expelled  at  each  systole  into  the 
aorta  is  therefore  greater,  while  it  is  smaller 
than  normal  when  the  pulse  is  accelerated. 
There  is  thus  a  twofold  reason  for  the  difference 
between  the  systolic  and  diastolic  pressures  with 
a  slow  and  a  quick  pulse.86 

This  may  be  rendered  clearer  by  the  diagram 
(Fig.  32),  where  the  dark  line  shows  a  trace 
which  might  be  obtained  by  a  manometer  with 

if 


'           \  / 

\S  ^'' 

FIG.  82.— Diagram  to  show  the  effect  of  pulse-rate  on  oscillation  of  tension 
or  pulse-pressure. 

a  moderately  quick  pulse.  The  interrupted  line 
shows  the  large  oscillations  caused  by  a  slow 
pulse,  and  the  finely  dotted  line  those  caused  by 
a  rapid  pulse.  In  these  curves  the  power  of  the 
heart  is  supposed  to  remain  the  same.  Under 
this  condition  a  slow  pulse  causes  great  oscilla- 
tion and  a  quick  one  small  oscillation  (Fig.  32). 

But  the  power  of  the  heart  is  a  very  important 
factor,  and  if  strong  in  proportion  to  resistance 
it  will  cause  large  oscillation.  If  feeble,  it  will 
cause  small  oscillation. 

Another  important  factor  is  the  condition 
of  the  capillaries.  If  dilated,  the  blood  flows 
quickly  through  them  and  oscillation  is  great.  If 


INFLUENCE  OF  CAPILLARIES          117 

contracted,  the  flow  is  slow  and  the  oscillation 
small  (Fig.  33). 

These  points  may  be  made  clearer  by  using 
as  an  example  some  curves  of  blood-pressure 
which  A.  B.  Meyer  and  I  took  in  1867  in  du 
Bois-Reymond's  laboratory  in  Berlin  (Fig.  33).36 
The  first  section  of  the  diagram  shows  the  normal 
pressure,  the  second  the  pressure  after  digitalis 
had  begun  to  exert  its  action,  and  the  third 


PIG.  83. — Tracing  of  the  blood-pressure  in  a  dog  under  the  influence  of 
digitalis.  I,  II,  and  III  show  progressive  slowing  of  the  pulse,  rise  of 
blood-pressure,  and  diminished  oscillation  due  to  contraction  of  the 
arterioles. 

when  the  action  of  digitalis  was  well  marked. 
The  general  effect  of  the  drug  is  to  slow  the 
pulse,  raise  the  tension,  and  increase  the  actual 
force  of  each  beat  of  the  heart. 

The  rise  of  tension  is  evidently  due  to  con- 
tracted capillaries,  for  if  they  remained  of  the 
same  size  in  the  third  section  as  in  the  first, 
the  higher  tension  should  drive  the  blood  more 
quickly  through  them  and  the  curve  should  fall 
more  quickly  during. diastole,  whereas  the  con- 
trary is  the  case.  The  power  of  the  heart  is 


n8    EXAMINATION  OF  BLOOD-PRESSURE 


increased  because  it  drives  the  blood  into  the 
aorta  against  a  higher  arterial  pressure,  but  it  is 
not  increased  in  proportion  to  the  resistance. 

Significance  of  Pulse-pressure  or  Oscilla- 
tion.— This  is  perhaps  most  easily  put  in  a 
tabular  form. 


Tension. 

Oscillation. 

Heart. 

Vessels. 

I. 

low 

much 

strong 

dilated 

2. 

M 

little 

weak 

„       (probably) 

3- 

moderate 

much 

strong 

moderately  contracted 

4- 

»» 

little             weak 

it 

5- 

high 

much 

strong 

contracted 

6. 

i) 

little 

weak 

" 

These  conditions  are   represented   diagram- 
rnatically  in  Fig.  34. 


Wl/l 

1/l/Wl/ 

V\AA 

WWVA 

SWW 

vvww 

/ 

z 

3 

* 

S 

e 

FIG.  84.—  Diagram  to  represent  the  relation  between  arterial  tension  and 
pulse-pressure. 

In  6  the  actual  power  of  the  heart  may  be 
greater  than  normal,  but  it  is  less  in  proportion 
to  the  resistance  it  has  to  overcome. 

Size  of  Vessels. — A  most  ingenious  instru- 
ment for  measuring  the  size  of  the  arteries  has 


PRESSURE  IN  VEINS  AND  CAPILLARIES  119 

been  devised  by  Dr  Oliver,  and  is  called  by  him 
the  arteriometer.37 

Measurement  of  Pressure  in  the  Veins. — 
This  may  be  done  by  choosing  any  convenient 
portion  of  a  subcutaneous  vein,  and  pressing  a 
sphygmomanometer  upon  its  distal  end  with 
sufficient  force  to  stop  the  flow  of  blood.  The 
proximal  part  is  then  emptied  of  blood  by 
pressing  the  tip  of  a  finger  along  it.  The 
pressure  of  the  pad  or  bulb  is  then  relaxed,  and 
the  pressure  noted  at  which  the  vein  again  fills.38 

A  simple  way  of  roughly  estimating  the 
venous  pressure  is  to  notice  at  what  height 
above  the  level  of  the  heart  the  veins  of  the 
hand  become  empty.  Normally,  they  should 
do  so  about  the  level  of  the  third  rib,  or  a  little 
above.  The  greater  the  venous  pressure,  the 
higher  must  the  hand  be  raised. 

Measurement  of  Pressure  in  the  Capil- 
laries.— The  method  of  doing  this  we  owe  to 
N.  von  Kries  and  Ludwig.39  It  consists  in  press- 
ing down  a  piece  of  glass  on  the  skin  by  a  weight 
or  spring,  and  noting  the  lowest  pressure  at 
which  the  skin  becomes  white.  It  is  best  done 
on  the  finger  or  lobe  of  the  ear. 

Another  method  is  that  of  von  Basch,  who 
employs  a  thistle-funnel  cut  short,  and  having 
a  side-tube  in  the  thistle  by  which  it  can  be 
connected  through  a  T-tube  with  an  aneroid 
and  air-bulb.  The  top  of  the  thistle  is  covered 
by  a  thin  piece  of  glass ;  the  lower  end  is 
fastened  by  cement  on  the  patient's  finger  just 
above  the  nail.  The  pressure  is  then  raised  by 
compressing  the  air-bulb ;  the  point  is  noted 


120     EXAMINATION  OF  BLOOD-PRESSURE 

when  the  skin  under  the  end  of  the  funnel 
becomes  pale,  and  the  pressure  is  read  off  on 
the  aneroid.40  This  method  can  be  applied  also 
to  ascertain  the  pressure  in  veins. 


LITERATURE. 

1  von  Basch,  Verhandl,  d.  PhysioL  Gesellsch.  zu  Berlin, 

Jahrg.  1879-80,  No.  7 ;  Berl.  klin.  Wochenschr., 
1887,  Nos.  11-16.  For  description  of  experiment, 
•vide  also  Lauder  Brunton,  Lancet,  I7th  October 
1908,  p.  1126. 

2  von  Basch,  "  Der  Sphygmomanometer  u.  seine  Verver- 

tung  in  der  Praxis,''  Berl.  klin.  Wochenschr.,  1887, 
vol.  xxiv.,  p.  181. 

3  Potain,  La  pression  arterielle  de  Fhomme,  etc.  (Paris : 

Masson,  1902) ;  and  Arch,  de  Physiol.,  1889,  vol.  '•> 
p.  556,  and  1890,  vol.  ii.,  p.  300. 

4  Oliver,   Blood  and  Blood  Pressure    (London  :  Lewis, 

1901),  p.  1 14  ;  Quart.  Journ.  of  Exp.  PhysioL,  vol.  iv., 
No.  i,  p.  45- 

5  Hill,  Further  Advances  in  Physiology,  p.  122  (London  : 

Arnold,  1909). 

6  Sahli,  Lehrb.  d.  Klin.   Untersuchungsmethoden,  Bd.  i., 

6  Aufl.,  1912;  and  "  Sphygmobolometrie,"  Corr.-Bl. 
f.  sch-weiz.    Aerzte,    1911,    No.    16 ;  Deutsch.   med. 
,      Wochenschr.,   1907;  ibid.,  1910,   No.  47;  Ztschr.  j. 
klin.  Med.,  vol.  72,  Nos.  i  and  2. 

7  Gaertner,    Wien.    med.    Wochenschr.,   1899,  vol.   xlix., 

p.  1412. 

8  Riva  Rocci,  Gaz.  Med.  d.  Torino,  1896,  voL  xlvii.,  p. 

981. 

9  Hill  and  Barnard,  Brit.  Med.  Journ.,   1897,  vol.  ii.,  p. 

904. 

10  Hawksley,  vide  C.  J.  Martin,  Brit.  Med.  Journ.,  22nd 

April  1905,  p.  865. 

11  Lauder  Brunton,  Lancet,  I7th  October  1908,  p.  1126. 

12  Janeway,  Clinical  Study  of  Blood  Pressure  (New  York 

and  London  :  Appleton,  1904). 


121 

18  von  Recklinghausen,  Arch.  f.  exp.  Path.  u.  Pharm., 
1901,  vol.  xlvi.,  p.  78  ;  and  ibid.,  1906,  vol.  lv.,  pp. 
375  and  412  ;  C.  J.  Martin,  Brit.  Med.  Journ.,  22nd 
April  1905,  vol.  i.,  p.  865. 

14  William    Russell,    Arterial   Hyfiertonus,    etc.,   p.    72 

(Edinburgh  and  London :  Wm.  Green  &  Sons, 
1907) ;  Herrington  and  Womack,  Proc.  Roy.  Soc.  of 
Med.,  London,  1909,  vol.  ii.,  p.  37. 

15  Vide  Kronecker  and  Magnus  Schmidt,  Arch.f.  Anat. 

u.  PhysioL,  physiol.  Abt.,  1909,  p.  331. 

16  Janeway,  op.  tit.,  p.  108  et  seq. 

17  Janeway,  op.  cit.,   p.   117;   Cabot  and  Bruce,  Amer. 

Journ.  Med.  Set.,  1907,  vol.  cxxxiv.,  p.  491  ;  Potain, 
Pression  arterielle,  etc.,  p.  53  (Paris  :  Masson,  1902). 

18  Ludwig    and    Sadler,   Ludwigs    Arbeiten    for    1869 

(Leipzig  :  Hirzel,  1870),  p.  89. 
18  Ibid.,  p.  96. 

20  Ibid.,  p.  90. 

21  Lauder   Brunton  and  Tunnicliffe,  Brit.  Med.  Journ., 

i6th  October  1897,  vol.  ii.,  p.  1073. 

22  Potain,  Pression  arterielle,  etc.,  p.  60  (Paris,  1902). 

23  Korotkow  and  Janowski,  quoted  by  Fellner,  Verhandl. 

d.  Kongressf.  inn.  Med.,  Wiesbaden,  1907,  vol.  xxiv., 
p.  404  et  seq.j  Oliver,  Proc.  Roy.  Soc.  of  Med. 
London,  28th  June  1910,  vol.  Hi.,  pt.  ii.,  Med.  Sect ,  p. 
207. 

24  Oliver,  Quart.  Journ.  of  Exp.  PhysioL,  1911,  vol.  iv., 

p.  44. 

25  Marey,   Tra-v.  Lab.,   1876,  vol.  ii.,  p.   313,  and  1878 

vol.  iv.,  p.  126;  Mosso,  1895,  Arch.  Nat.  de  Biol^ 
vol.  xxiii.,  p.  177  ;  Roy  and  Adami,  Practitioner, 
1890,  vol.  xlv.,  p.  32. 

26  Oliver,  Quart.  Journ.  of  Exp.  PhysioL,  1911,  vol.  iv., 

p.  50 ;  Eckenstein,  Brit.  Med.  Journ.,  1910,  vol.  ii., 
p.  1765. 

27  Sahli,  Corr.-Bl.f.  schweiz.  Aerzte,  1911,  No.  16. 

28  von  Recklinghausen,  Arch.  f.  exp.  Path,  u    Pharm , 

1906,  vol.  lv.,  p.  432. 

29  Pachon,  Compt.  rend,  de  la  Soc.  de  Biol.,  8th  and  15th 

May  1909,  vol.  Ixvi.,  pp.  723  and  726. 

30  Erlanger,  An>er.  Journ.  of  PhysioL,  1902,  vol.  vi.,  p.  22  ; 

1904,  vol.  xi.,  p.  14. 

K 


122  LITERATURE 

31  Hirschfelder,  Diseases  of  the  Heart  and  Aorta,  p.  21 

(Lippincott  Co.,  1910). 

32  Gibson,  Proc.  Roy.  Soc.,  Edinburgh,  1907-8,  vol.  xxviii., 

p.  343  et  seq. 

33  Strassburger,  Ztschr.f.  klin.  Med.,  vol.  liv.,  p.  377. 

34  Jane  way,  Clinical  Study  of  Blood  Pressure,  p.    109 

(New  York  and  London,  1904). 

86  Lauder   Brunton,  Brit.   Med.  Journ.,  5th    November 
1910,  voL  ii.,  p.  1389. 

36  Lauder  Brunton  and  A.  B.  Meyer,  Jotirn.   of  Anat. 

and  PhysioL,  1873,  vol.  vii.,  p.  134. 

37  G.  Oliver,  Blood  and  Blood  Pressure,  p.  127  (London  : 

Lewis,  1901). 

38  G.   Oliver,   "Lecture    on   Hamomanometry,"  Lancet, 

22nd  July  1905,  vol.  ii.,  p.  201. 

39  Ludwig  and  Kries,  Ludwigs  Arbeiten,  1875,  p.  69. 

40  v.  Basch,  S.  Arch,  des  scienc.  biol.  d.  St  relersb,,  1904, 

vol.  xi.,  suppl.,  pp.  117-136. 


CHAPTER  VI 

EXAMINATION   OF   THE   CIRCULATION 

Cardiographs  —  Apex  -  beat  Cardiograms  —  Sphygmo- 
graphs  —  Carotid  Pulse  —  Mode  of  Applying  the 
Sphygmograph  —  Sphygmograms  —  Fallacies  —  In- 
verted Tracings — Venous  Pulse — Pseudo-pulsations 
in  Jugular  Vein — Sphygmographic  tracing  of  Venous 
Pulse — Characters  of  the  Venous  Pulse — Propagation 
of  the  Pulse-wave  —  Delay  —  Practical  Use  of  the 
Sphygmograph — X-ray  Examination  of  the  Heart — 
Skiagrams — String  Galvanometer — Leads — Electro- 
cardiograms— Coagulometer — Viscosity  of  the  Blood. 

Cardiographs. — All  the  instruments  I  have 
hitherto  described  have  been  chiefly  for  measur- 
ing the  amount  of  blood-pressure,  or  the  size  of 
the  artery,  but  they  do  not  give  us  any  indica- 
tion of  the  mode  of  contraction  of  the  heart  or 
the  nature  of  the  pulse-wave.  These  have  chiefly 
been  worked  out  by  instruments  devised  by  the 
late  Professor  Marey,1  and  the  principle  upon 
which  most  of  them  depend  is  that  of  the  trans- 
mission of  motion  by  air  from  one  elastic  vessel 
to  a  second,  on  which  rests  a  light  lever  which 
amplifies  the  movements  and  records  them  on  a 
revolving  cylinder.  By  introducing  an  elon- 
gated bulb  through  the  aortic  valves  into  the 

123 


124    EXAMINATION  OF  THE  CIRCULATION 


g-i-SSi 
>  ?  ®  .9  ""' 


.S  'o  ~  c  • 


a  ^  o  S 

S3§^3P 


CARDIOGRAPHS  125 

ventricle,  Marey  obtained  tracings  of  the  changes 
in  pressure  throughout  the  ventricular  cycle,  as 
shown  in  Fig.  35,  where  the  upper  tracing 
shows  the  rise  of  pressure  in  the  heart,  and  the 
lower  in  the  aorta.  In  the  cardiac  tracing 
there  is  first  a  slight  rise,  due  to  the  auricular 
contraction,  then  a  sudden  rise,  which  becomes 
somewhat  slower  as  it  increases.  At  the  top  of 
this  is  a  plateau  showing  several  oscillations, 
then  a  sudden  descent,  marked  at  its  end  by  a 
little  wave,  and  then  an  almost  level  line,  after 
which  the  same  sequence  again  occurs.2  The 
alteration  in  rapidity  of  ascent,  which  takes 
place  about  the  middle  of  the  systole,  probably 
indicates  the  time  at  which  the  auriculo-ven- 
tricular  valves  become  screwed  together,  for 
this  is  the  kind  of  closure  actually  witnessed  (p. 
74),  and  the  aortic  valves  are  forced  open  by  the 
increasing  pressure  behind.  The  oscillations 
which  occur  on  the  plateau,  according  to  Marey, 
do  not  indicate  mere  vibrations  of  the  auriculo- 
ventricular  valves,  but  real  oscillations  in  them 
and  in  the  blood  on  both  sides  of  them.  The 
sharp  fall  indicates  the  diastolic  relaxation  of 
the  ventricle,  and  the  little  wave  at  the  end 
marks  the  time  of  closure  of  the  sigmoid 
valves. 

When  the  bulb  is  withdrawn  from  the  ventricle 
into  the  aorta,  a  tracing  is  obtained  which  is 
almost  exactly  like  that  of  the  ventricle  with 
the  lower  part  of  it  cut  off,  and  a  gradual 
descent  substituted  for  the  sudden  fall.  If  the 
aorta  were  rigid,  this  form  of  curve  would  be 
transmitted  on  to  the  periphery,  and  we  do, 


126    EXAMINATION  OF  THE  CIRCULATION 

indeed,  find  that  the  radial  pulse-tracing  shows 
the  characters  of  the  aortic  pulse,  namely,  the 
flattened  plateau  and  slow,  rather  even,  descent 
whenever  the  elasticity  of  the  arteries  is  im- 
paired by  atheromatous  change,  as  in  old  people, 
or  by  great  distension  from  high  arterial  pres- 
sure, as  in  cases  of  Bright's  disease  (Fig.  36).3 

Apex-beat  Cardiograms. — The  cardiograph 
which  is  used  to  register  the  apex  impulse  is  a 
tambour  with  a  spring  to  press  it  against  the 


FIG.  86. — Diagram  to  show  the  analogy  of  the  senile  pulse  to  the 
ventricular  beat.  (After  Marey.)  The  unbroken  line  is  the 
sphygmographic  tracing  ;  the  dotted  line  shows  the  ventricular 
tracing. 

chest  wall,  and  this  is  connected  by  india-rubber 
tubing  with  a  writing  tambour  and  lever.  The 
tracing  is  somewhat  like  that  of  the  aorta,  but 
it  is  higher  and  falls  more  abruptly.  The 
abruptness  of  the  fall  depends  to  a  considerable 
extent  on  the  pressure  of  the  cardiograph.4 
The  tracing  may  vary  very  much  in  the  same 
individual  under  various  conditions.6 

Sphygmographs  are  instruments  for  mag- 
nifying and  recording  the  movements  of  the 
pulse.  In  most  of  them  a  spring  rests  upon  the 
artery  and  its  movements  are  transmitted  to  a 


SPHYGMOGRAPHS  127 

lever,  which  greatly  magnifies  them  and  records 
them  upon  a  moving  surface  either  directly  or 
through  a  tambour.  There  are  many  forms. 
Of  these,  Marey's6  original  one  probably  gives 
the  most  accurate  records ;  but,  on  account  of  its 
cheapness,  portability,  and  ready  application, 
Dudgeon's7  is  the  most  favoured  in  this 
country.  Jacquet's  is  similar  in  form,8  but 
is  provided  with  a  time-marker  and  also  a 
tambour  for  registering  at  the  same  time  the 
movements  of  the  apex  beat  and  respiration. 
Mackenzie's  polygraph  can  also  register  these 
latter  movements,  and  in  it  the  movements  of 
the  pulse  both  in  the  radial  artery  and  jugular 
veins,  are  transmitted  to  a  tambour. 

One  exception  to  the  rule  I  have  just  given 
is  Kronecker's  sphygmograph,  which  gives  the 
true  form  of  the  pulse  without  the  tracing  being 
deformed  in  any  way  by  the  oscillations  of  the 
instrument.  It  consists  of  a  modified  capillary 
electrometer,  and  the  movements  of  a  very  fine 
mercurial  column  are  photographed  on  a  revolv- 
ing cylinder.9  One  interesting  point  which 
this  brings  out  is  that  the  pointed  top  of  the 
ascending  curve  is  not  altogether  due  to  a  jerk 
of  the  recording  lever,  as  is  generally  assumed, 
but  really  indicates  the  abrupt  shock  given  to 
the  artery  by  the  impact  of  blood  driven  into  it 
by  the  ventricular  systole. 

Carotid  Pulse. — For  this  artery  it  is  most 
convenient  to  use  a  tambour  with  a  knob  and 
spring  like  a  small  cardiograph,  rather  than  a 
lever.  The  pulsations  are  transmitted  to  a 
writing  tambour. 


128     EXAMINATION  OF  THE  CIRCULATION 

Application  of  the  Sphygmograph.  —  The 
radial  artery  is  the  most  convenient,  and  the 
tracings  are  most  accurate  when  taken  from  it 
just  as  it  lies  over  the  radius.  Sometimes  such 
tracings  show  very  small  amplitude  and  better 
ones  are  got  from  the  artery  a  little  higher  up. 
The  pelotte  of  the  sphygmograph  ought  to  be 
exactly  over  the  artery,  and  to  ensure  this  it  is 
well  to  mark  the  vessel  with  a  blue  dermato- 
graph  pencil  before  tying  on  the  instrument. 
It  is  usually  fastened  on  by  straps,  but  a  great 
saving  of  time  is  effected  by  using  two  elastic 
bands,  which  are  simply  twined  together  behind 
the  wrist  without  tying  them.  They  generally 
hold  tightly  enough,  and  are  easily  unfastened  as 
well  as  fastened.  When  the  elastic  is  becoming 
worn  it  must  be  replaced  by  new.  In  most 
patients  it  is  advisable  to  extend  the  wrist 
somewhat,  which  can  be  done  by  placing  a  book 
or  pad  of  some  kind  under  it. 

It  is  sometimes  difficult  to  get  the  lever  to 
write  exactly  on  the  right  part  of  the  paper,  and 
to  overcome  this  difficulty  I  have  had  a  screw 
adjustment  applied  by  Mr  Hawksley  to 
Dudgeon's  sphygmograph. 

Sphygmograms.  —  In  a  perfectly  healthy 
person  the  arteries  are  circular  in  section. 
They  dilate  as  each  wave  of  blood  is  sent  in 
from  the  heart,  and  they  contract  during  the 
intervals  of  the  cardiac  pulsations ;  but  this 
dilatation  and  contraction  is  very  slight  and  is 
not  the  pulse  which  is  usually  felt  by  the  finger. 
In  feeling  the  pulse  the  artery  is  squeezed  out 
of  shape  by  the  pressure  of  the  finger,  so  that 


SPHYGMOGRAMS  129 

the  section  becomes  oval  instead  of  circular. 
The  increased  pressure  within  the  vessels  at 
each  beat  of  the  heart  tends  to  restore  the 
circular  section,  and  it  is  this  movement 
which  is  felt  by  the  finger  and  recorded  by 
the  sphygmograph.  The  pulse  wave  as  thus 
recorded  by  the  sphygmograph  in  the  radial 
artery  differs  a  good  deal  from  that  in  the 
carotid.  In  the  carotid  the  systolic  rise  is  much 
like  that  which  occurs  at  the  end  of  the  ventri- 
cular contraction,  Fig.  35,  but  it  is  much 
modified  by  the  elasticity  of  the  arteries  on  its 


Fio.  37. — Tracing  from  normal  pulse. 

way  to  the  radial,  so  that  in  a  normal  sphygmo- 
gram  we  notice  a  fairly  sudden  and  extensive 
systolic  rise  followed  by  a  moderately  quick  fall 
for  a  certain  distance,  then  a  second  rise 
followed  by  a  second  slower  fall  (Fig.  37). 

A  quick  rise  indicates  that  the  heart  is  acting 
strongly  relatively  to  the  resistance  opposed  to 
it  by  the  pressure  of  blood  in  the  arteries.  It 
may  be  due  either  to  a  strongly  acting  heart 
or  low  arterial  pressure  from  emptiness  of  the 
arteries. 

A  slow  rise  indicates  that  the  heart  is  rela- 
tively feeble.  It  maybe  due  to  actual  weakness 


130    EXAMINATION  OF  THE  CIRCULATION 

of  the  ventricle  or  to  the  great  resistance  opposed 
to  it  by  high  blood-pressure. 

A  quick  fall  indicates  that  the  arterial  system 
empties  itself  easily  either  through  the  systemic 
capillaries  into  the  veins  or  backwards  into  the 
heart,  or  both.  In  aortic  regurgitation  during 
the  diastole  the  blood  flows  back  into  the 
heart  as  well  as  onwards  through  the  capil- 
laries. The  arterial  system  therefore  becomes 
abnormally  empty  and-  the  pulse  tracing  falls 
very  low.  At  the  same  time  the  ventricle  gets 


.FiG.  38. — Tracing  from  a  case  of  aortic  regurgitation,  showing 
hook  at  top  of  tracing,  sudden  fall,  and  extensive  movement. 

a  double  supply  of  blood,  onward  from  the 
auricle  and  backward  from  the  aorta.  It  there- 
fore shoots  a  large  wave  into  the  aorta,  so  that 
the  pressure  rises  suddenly  and  greatly.  This 
causes  the  lever  to  ascend  so  quickly  that  its 
own  inertia  carries  it  too  far  and  a  little  crochet 
or  hook  is  formed  at  the  summit  of  the  tracing 
(Fig.  38). 

When  the  quick  fall  of  the  sphygmographic 
tracing  is  due  to  dilated  capillaries  it  is  usually 


DICHROTIC  PULSE  131 

broken  by  a  second  wave,  known  as  the  dichrotic 
wave  (Fig.  39).  This  is  usually  all  the  more 
marked  the  lower  the  tension  is.  When  the 
tension  is  raised  it  may  disappear  completely, 
and  when  the  tension  is  very  low  it  may  become 
so  marked  as  almost  to  rival  the  primary  wave 
in  height  It  is  then  called  hyperdichrotic. 
The  most  marked  tracing  of.  it  that  I  ever 
obtained  was  from  a  youth  who  had  had  very 
profuse  haemoptysis,  so  that  he  had  become 
almost  drained  of  blood. 

As  a  rule,  exaggeration  of  the  dichrotic  wave 


PIG.  39.— Dichrotic  pulse. 

means  increased  power  of  the  heart  in  relation 
to  the  resistance  it  has  to  overcome,  so  that  the 
elasticity  of  the  arteries  is  fully  called  into  play, 
just  as  an  elastic  ball  thrown  against  the  floor 
rebounds  higher  the  more  force  that  is  used. 
When  the  aortic  valves  are  incompetent,  this 
rebound  is  less  marked  or  absent.  This  is  one 
of  the  arguments  used  to  prove  that  the  dichrotic 
wave  is  due  to  a  rebound  from  the  aortic  valves 
rather  than  from  the  periphery.  Sometimes 
the  descending  limb  is  broken  by  three  or  even 
four  waves  forming  a  trichrotic  or  tetrachrotic 
pulse.  These  are  supposed  to  be  due  to  waves 


1 32    EXAMINATION  OF  THE  CIRCULATION 

from  the  aorta  reflected  back  from  the  peripheral 
vessels  and  then  back  again. 

A  slow  fall  indicates  that  the  blood  is  flowing 
slowly  through  the  capillaries.  It  may  occur  in 
perfectly  healthy  persons  from  contraction  of 
the  capillaries  by  cold  (i,  Fig.  4o),10  and  is  gener- 
ally present  in  elderly  people  with  high  tension. 

Fallacies  in  Sphygmograms. — Quite  apart 
from  any  imperfections  in  the  instrument 


Flo.  40. — Effect  of  cold  in  contracting  the  capillaries  and  raising  the 
blood-pressure,  and  of  warmth  in  dilating  the  capillaries  and  lower- 
ing the  blood-pressure.  1.  Effect  of  cold.  2.  Normal.  8.  Effect  of 
warmth.  (After  Marey.) 

employed,  the  way  in  which  the  sphygmograph 
is  applied  to  the  arm  may  cause  very  different 
tracings  to  be  obtained.  If  the  pelotte  does  not 
rest  fairly  on  the  artery  the  pulse  wave  may 
appear  very  small  and  a  dichrotic  wave  may 
disappear  (Fig.  41). 

In  old  persons  with  somewhat  tnickened 
arteries  the  senile  pulse  with  a  marked  plateau 
(p.  126)  is  common,  but  sometimes  this  character 


FALLACIES  IN  SPHYGMOGRAMS       133 

is  obscured  (Fig.  42)  and  quite  a  different  tracing 
is  obtained  (Fig.  43),  because  instead  of  the  lever 
of  the  sphygmograph  being  simply  raised  at  each 


A        ft        A 


N~.M.  NovT  £ 


9ii.  Fulsewo.  Tension  153. 


Pro.  47. — Different  tracings  produced  by  different  npplications  of 
Dudgeon's  sphygmograph  in  a  case  of  pneumonia.  The  sphygmo- 
graph was  not  removed  from  the  arm,  but  its  position  and  pressure 
were  altered  between  the  tracings.  The  age  of  the  patient  was  72. 


FIG.  42.— Three  successive  tracings  from  a  pulse,  taken  at  the  same  time 
and  under  the  same  conditions,  but  With  altered  application  of  Dud- 
geon's sphygmograph. 

pulse  by  the  increased  tension  in  the  artery, 
it  is  suddenly  driven  up  by  the  longitudinal 
elongation,  which  is  often  distinctly  visible  in 
such  cases. 


134    EXAMINATION  OF  THE  CIRCULATION 


FIG.  48. — Two  tracings  from  the  same  pulse.    In  a  the  senile  plateau 
distinct,  in  b  it  is  masked  by  the  sudden  impulse  given  to  the  lever. 


Fia.  44. — Tracing  from  a  locomotive  artery  in  a  man  aged  82. 


FIG.  45.— Tracing  showing  excessive  and  irregular  movement  of  lever  due 
to  locomotive  arteries.    Patient  aged  61 ;  pulse  76,  tension  285  mm. 


PSE  UDO-  VENO  US  P  ULSA  T10N          135 

In  Dudgeon's  sphygmograph  the  connection 
between  the  lever  and  pulse-pad  is  loose,  and 
an  obviously  incorrect  tracing  is  sometimes 
obtained  (Fig.  45). 

I  have  never  obtained  such  inaccurate  tracings 
with  Marey's  sphygmograph,  and  I  regard  it 
as  a  much  more  trustworthy  instrument  than 
Dudgeon's,  but  the  ease  and  rapidity  with  which 
the  latter  can  be  applied  render  it  much  more 
convenient. 

Inverted  Tracings. — When  the  pelotte  is 
placed  at  one  side  of  a  locomotive  artery 


FIG.  46.— Inverted  tracing.  The  upper  tracing  is  the  normal  one,  the 
lower  is  inverted.  In  taking  these  tracings  the  sphygmograph 
remained  on  the  arm,  but  its  position  over  the  artery  was  slightly 
altered. 

instead  of  upon  it,  the  elongation  of  the  artery 
gives  a  drag  instead  of  a  push  to  the  pelotte, 
and  an  inverted  tracing  is  produced  (Fig.  46). 

Venous  Pulse. — As  a  rule,  no  pulsation  is 
visible  in  any  vein,  but  in  tricuspid  regurgita- 
tion  the  blood  is  driven  back  by  the  right 
ventricle  through  the  auricle  into  the  jugular 
vein,  giving  rise  to  visible  pulsation. 

Pseudo-pulsation  in  the  left  Jugular  Vein. — 
In  some  persons  an  apparently  well-marked 
pulsation  occurs  in  the  left  jugular  vein  only.  This 
is  probably  due  to  alternate  compression  and 
relaxation  of  the  innominate  vein  by  the  pulsa- 


136    EXAMINATION  OF  THE  CIRCULATION 

tions  of  the  aortic  arch.11  It  can  be  imitated  in 
the  jugular  of  either  side  by  alternately  compres- 
sing it  with  the  finger  and  releasing  it. 

Sphygmographic  Tracings  of  Venous  Pulsa- 
tion.— The  method  of  taking  tracings  from  the 
jugular  vein  was  introduced  by  Mackenzie,  and 
it  has  added  much  to  our  knowledge  of  the 
physiology  and  pathology  of  the  heart's  move- 
ments.12 The  tracing  is  taken  by  a  tambour 
and  lever  in  the  same  way  as  a  cardiogram,  but 
in  place  of  a  cardiograph  such  as  is  used  for  the 
heart  a  small  funnel  or,  better,  a  shallow  metal 
pan  is  used  as  a  receiver.  One  part  of  its 
circumference  is  flattened  so  as  to  allow  it  to 
be  applied  more  closely  above  the  clavicle.  In 
using  it  the  patient  should  lie  on  .his  back  with 
his  head  and  neck  supported  by  a  pillow,  his 
head  turned  to  one  side  and  his  neck  flexed. 
The  receiver  is  then  pressed  down  on  the 
jugular  bulb,  and  the  pulsations  of  the  vein  are 
transmitted  to  the  tambour.  If  any  difficulty  is 
experienced  in  obtaining  a  tracing  here  the 
receiver  should  be  moved  a  little  more  to  the 
right  and  placed  over  the  junction  of  the  jugular 
and  subclavian  veins. 

Characters  of  the  Venous  Pulse. — The  trac- 
ing usually  presents  two  rises  and  two  falls  in  a 
cycle  (Fig.  47).  The  first  rise  is  large  and  sharp. 
It  is  due  to  the  auricular  contraction.  The  first 
fall  is  rapid,  owing  to  the  auricle  having  been 
emptied.  The  second  rise  is  slow,  and  is  due  to 
the  gradual  filling  of  the  auricle.  The  second 
fall  is  slight,  and  is  due  to  the  blood  flowing  into 
the  empty  ventricle.  As  the  first  sharp  rise 


CHARACTERS  OF  VENOUS  PULSE      137 

coincides  with  the  auricular  systole,  it  allows  the 
time  of  this  to  be  exactly  noted  and  compared 
with  the  carotid  pulse,  which  nearly  coincides 
with  the  ventricular  systole.  It  is  thus  easy  to 
ascertain  whether  the  normal  sequence  between 
auricular  and  ventricular  systoles  exists,  or 
whether  any  heart-block  is  present. 


PIG.  47.— Venous  pulse  in  the  jugular  and  its  time- relations  to  the  apex 
beat  and  carotid  and  radial  pulses.  The  perpendicular  lines  show 
the  time  of  (1)  Beginning  of  auricular  systole ;  (2)  beginning  of  ven- 
tricular systole;  (8)  beginning  of  carotid  pulse;  (4)  beginning  of 
radial  pulse  ;  (5)  closure  of  semi-lunar  valves ;  (6)  opening  of  tricuspid 
valves.  (After  Mackenzie.)— From  Diseases  of  the  Heart,  by  James 
Mackenzie,  M.D.,  F.B.C.P.,  p.  107.  London  :  Froude,  and  Hodder& 
Stoughton,  1903. 

For  a  method  of  showing  diagrammatically 
the  relative  position  of  the  curves  and  the  delay 
in  transmission,  vide  p.  418,  Fig.  in. 

Propagation  of  the  Pulse-wave.  Delay. — 
The  pulse  -  wave  travels  at  a  rate  of  about  30 
feet  per  second.13  Counting  from  the  commence- 

L 


138    EXAMINATION  OF  THE  CIRCULATION 

ment  of  the  opening  of  the  valves,  which  takes 
about  one-twentieth  of  a  second,  the  pulse-wave 
takes  one-tenth  of  a  second  to  reach  the  carotid, 
and  rather  less  than  two-tenths  to  reach  the 
radial  artery.  In  timing  cardiac  murmurs  it  is, 
therefore,  better  to  take  the  carotid  than  the 
radial  pulse.14 

Practical  Use  of  the  Sphygmograph. — The 
chief  uses  of  the  sphygmographic  tracing  are : — 

(1)  To  show  the  presence  or  absence  of  elas- 
ticity within  the  arteries,  as  evidenced  by  the 
more   or    less    complete    modification    of   the 
systolic  plateau. 

(2)  The   strength  or  weakness  of  the  heart, 
as  compared  with  the  pressure  it  has  to  over- 
come, as  shown  by  the  quick  or  slow  rise  during 
systole. 

(3)  The  condition  of  contraction   or  relaxa- 
tion of  the  arterioles,  shown  by  the  slowness  or 
rapidity  of  the  diastolic  fall  and  by  the  more  or 
less  marked  dichrotism. 

It  cannot  replace  the  sphygmomanometer, 
•but  when  used  along  with  it  may  afford  useful 
information  regarding  the  condition  both  of  the 
heart  and  vessels. 

X  ray  Examination  of  the  Heart.  —  By 
placing  a  luminous  vacuum  tube  at  one  side  of 
the  body,  and  a  fluorescent  screen  upon  the 
other,15  the  shadow  of  the  heart  is  thrown  upon 
the  screen  so  that  the  size  and  movements  of 
its  different  parts  may  be  seen,  hypertrophy, 
dilatation,  or  aneurism  observed,  and  even  heart- 
block  diagnosed. 

Skiagrams. — A  sensitised  plate  may  be  put 


STRING  GALVANOMETER  t& 

in  the  place  of  the  screen,  and  thus  a  permanent 
record  of  the  condition  of  the  heart  is  obtained. 

String  Galvanometer.  —  The  detection  of 
auricular  fibrillation  in  man  has  only  recently 
been  rendered  possible  by  the  use  of  electro- 
cardiograms. In  1876  Marey,16  and  in  1880 
Burdon-Sanderson  and  Page17  examined  the 
electric  changes  which  accompany  the  cardiac 
movements  by  means  of  a  capillary  electrom- 
eter, and  in  1887  Waller18  found  with  the 
same  instrument  that  these  electric  changes  can 
be  observed  in  an  intact  animal.  The  intro- 
duction of  the  very  delicate  string  galvanom- 
eter of  Einthoven19  has  greatly  increased  the 
accuracy  of  observations.* 

This  instrument  as  described  by  Kraus  and 
Nicolai  consists  of  a  very  delicate  quartz  fibre, 
silvered  to  make  it  conduct,  and  stretched 
between  the  poles  of  a  powerful  electromagnet. 
When  a  current  passes  through  the  fibre  it  is 
deflected  at  right  angles  to  the  magnetic  field. 
The  ends  of  the  wire  are  connected  to  two 
small  pails  containing  saline  solution.  Into 
these  the  two  hands,  or  one  hand  and  one  foot, 
of  the  patient  are  placed.  The  current  produced 
by  the  heart  is  conducted  from  them  through 
the  wire,  and  according  to  the  direction  in  which 
it  passes  the  wire  is  attracted  by  one  or  other 
pole.  The  shadow  of  the  wire  is  thrown  by  a 

*  The  instrument  and  its  employment  and  uses  have 
been  fully  described  by  F.  Kraus  and  Nicolai  (Das 
Elektro  Kardiogramm,  Veit,  Leipzig,  1910),  and  Lewis 
(Mechanism  of  the  Heart  Beat,  Shaw  &  Sons,  London, 


140    EXAMINATION  OF  THE  CIRCULATION 

strong  light  or  reflected  from  the  string  on  a 
revolving  cylinder  covered  with  sensitised  paper. 
Before  reaching  the  paper  it  passes  through  a 
small  slit  at  right  angles  to  the  wire,  so  that  only 
the  motions  of  a  point  in  the  wire  are  recorded. 
If  the  wire  cuts  off  the  light  from  the  paper  its 
motions  are  indicated  by  a  white  line,  but  if  the 
movement  is  recorded  by  reflection,  the  move- 
ments of  the  wire  are  in  black.  The  fibre  is  so 
thin  that  it  could  not  bear  the  strain  of  being 
stretched  horizontally,  so  that  in  practice  it  is 
vertical,  and  the  recording  cylinder  is  horizontal ; 
but  as  the  curves  are  always  read  vertically, 
it  is  easier  to  understand  their  production  when 
the  apparatus  is  represented  as  in  the  diagram, 
in  which  position  it  would  produce  vertical 
curves  (Fig.  48).  The  instrument  used  by 
Waller  differs  from  this. 

Leads. — Waller  gives  the  subjoined   system 
of  leads  : — * 

Lead  I.        Right  hand  and  left  hand  =    Transverse. 

Lead  II.       Right  hand  and  left  foot  =    Axial  (=IV.). 

Lead  III.     Left  hand  and  left  foot  •=  Left  lateral  ( =  V.). 

Lead  IV.     Right  hand  and  right  foot  =    Right  lateral  (= 

II.,  axial). 

Lead  V.      Left  hand  and  right  foot  =    Equatorial  (  =  111.). 

Lead  VI.     Right  foot  and  left  foot  =    Inferior. 

Lead  VII.   Mouth  and  left  hand  =    Left  superior. 

Lead  VIII.  Mouth  and  right  hand  =    Right  superior. 

Lead  IX.    Mouth  and  left  foot  =    Left  inferior. 

Lead  X.      Mouth  and  right  foot  =    Right  inferior. 

He   regards   the   two   feet  as   iso-electric,  and 
consequently   Lead    III.   (left   lateral)   and  V. 
(equatorial)  as  practically  equivalent ;  Lead  II. 
(axial)  and  Lead  IV.  are  also  equivalent. 
*  Lancet^  24th  May  1913,  vol.  i.,  p.  1435 


ELECTRO-CARDIOGRAMS  141 

Setting  aside  the  superior  leads,  the  Leads  I., 
IV.,  and  III.  are  equal  to  Einthoven's  *  trio — 
viz.,  transverse,  axial,  and  left  lateral. 

Electro-cardiograms.20  —  The  electric  condi- 
tion of  the  base  or  apex  of  the  heart  is  conducted 
to  the  arm  or  leg  nearest  it,  and  is  thence 
transmitted  to  the  galvanometer.  The  right 
arm  or  leg  being  nearest  to  the  base  shows  its 
electrical  condition,  and  the  left  arm  or  leg 
shows  that  of  the  apex.  The  best  electro-car- 
diograms are  got  from  the  right  hand  and  left 
foot,  but  it  is  more  convenient  to  take  them  from 
the  two  hands. 

The  physiological  fact  on  which  they  depend 
is  that  the  excited  part  of  a  muscle  becomes 
electro-negative  (usually  indicated  by  — )  to  the 
non-excited  parts,  which  are  therefore  positive 
(  +  )toit. 

If  an  excitation  starts  at  one  end,  A,  of  a 
straight  muscle  with  parallel  fibres  and  travels 
to  the  other  end,  B,  the  electric  variation  would 
be  that  A  would  first  be  negative  and  then 
positive  to  B.  This  is  known  as  diphasic  varia- 
tion. If  equal  currents  were  to  start  from  both 
ends  at  the  same  time,  but  in  opposite  directions, 
they  would  neutralise  each  other,  and  there 
would  be  no  deflection  of  the  wire  at  all. 

In  a  normal  cardiogram  there  are  three 
deflections  or  groups  of  deflection.  The  first  is 
associated  with  the  auricular,  and  the  second 

*  Einthoven :  "  Ueber  die  Form  des  Menschlichen 
Electrocardiogramms,"  PfliigeSs  Archiv,  vol.  lx.,  p.  101, 
1895  ;  "  Weiteres  iiber  das  Electrocardiogramm,"  Pfluger's 
Archiv,  vol.  cxxii.,  p.  517,  1908. 


142    EXAMINATION  OF  THE  CIRCULATION 

and  third  with  the  ventricular,  systole.     These 
have   been    indicated    by   different    letters    by 


Jiprth 


n 


Pio.  48.—  String  galvanometer.    (Very  diagrammatic,  BO  much  so  that  it 

may  be  regarded  by  some  as  incorrect.) 

E.M.  indicates  the  poles  north  and  south  of  a  powerful  electro- 
magnet, between  which  a  metal  string  (wire),  W,  passes.  Its  two  ends 
are  placed  in  two  jars  containing  saline  solution,  J  and  J'.  Into  J 
the  right  hand,  and  into  J'  the  left  hand  or  left  foot  are  placed,  so  as  to 
conduct  the  current  from  the  heart  through  the  wire.  II  is  the  heart  at 
the  beginning  of  systole.  The  base  is  then  negative,  -  ,  to  the  apex,  +, 
and  the  current  passes  from  it  through  the  limbs  and  wire  in  the  direc- 
tion shown  by  the  unbroken  line.  D  indicates  thedirection  in  which  the 
wire  then  moves.  H'  is  the  heart  at  the  end  of  systole,  and  the  apex 
is  then  negative,  -  ,  to  the  base,  +,  so  that  the  current  passes  in  the 
opposite  direction,  as  shown  by  the  broken  line,  and  the  wire  moves 
in  the  direction  indicated  by  D'.  El.  is  the  source  of  light,  and  L  the 
lens  by  which  the  light  is  concentrated  on  W,  so  as  to  throw  its 
shadow  on  the  recording  cylinder  C.  8  is  a  screen  with  a  narrow  slit 
in  it  to  cut  off  superfluous  light,  and  make  the  shadow  of  W  sharper 
on  the  screen.  As  it  is  the  shadow  of  the  wire  which  is  photographed 
on  the  sensitised  paper  on  the  cylinder,  the  curve  appears  white  on  a 
dark  ground,  unless  the  original  curve  is  used  as  a  negative  from 
which  to  print  copies.  In  practice  also  the  wire  is  vertical,  in  order  to 
avoid  dragging,  and  the  cylinder  is  horizontal. 

various  writers.    The  simplest  is  that  of  Waller, 
but  a  good  one  also  is  that  of  Nicolai,21  who 


ELECTRO-CARDIOGRAMS  143 

indicates  the  auricular  variation  by  A  and  the 
initial  end  of  the  ventricular  variation  by  /  and 
its  final  one  by  F.  All  three  are  succeeded  (post) 
by  slight  variations  in  an  opposite  direction, 
which  are  indicated  by  Ap,  Ip,  and  Fp.  The 
variations  /and  P  have  slight  opposite  variations 
anterior  to  them,  indicated  as  la  and  Fa.  The 


FIG.  49.— Diagram  of  an  electro-cardiogram.  (After  Kraus  and  Nicolai.) 
A  =  auricular  variation;  I  =  initial  variation;  f  =  final  variation; 
Ap  =  post-auricular  negative  variation ;  Ip  =  post-initial  negative  varia- 
tion ;  Fp  =  post-final  negative  variation ;  Jo  =  ante-initial  negative 
variation ;  Fa  =  ante-final  negative  variation :  h  =  time  lost  in  the 
bundle  of  His ;  w  =  time  lost  in  the  cardiac  walls ;  p=pause  of  heart.* 

*  In  Kraus  and  Nicolai's  diagram,  w  (wall)  is  indicated  by  t  (Treibwerk). 

period  when  the  excitation  is  passing  through 
His's  bundle  is  indicated  by  h  ;  that  time  when 
it  is  passing  in  more  or  less  different  directions 
through  the  wall  of  the  ventricle,  so  that  they 
counteract  one  another,  and  no  variation  is 
observed,  is  indicated  by  wt  and  the  pause  in 
which  there  are  no  currents  by  p. 


144     EXAMINATION  OF  THE  CIRCULATION 


Different  authors  have  denoted  various 
deflections  in  an  electro-cardiogram  by  different 
letters  so  that  it  is  sometimes  difficult  to  compare 
them  As  Waller  was  the  first  to  discover  the 
electro-cardiogram  his  nomenclature  ought  per- 
haps to  be  followed,  and  is  certainly  the  simplest, 
but  he  does  not  give  a  letter  of  indication  for 
all  parts  of  the  cardiogram,  and  I  therefore 
append  here  a  table  of  the  letters  used  by 
different  authors  to  designate  the  parts. 


Kraus 
and 
Nicolai. 

Bint- 

h<  jvc  ii. 

Waller. 

Positive  waves  — 

Auricular  waves         .        .        . 

A 

P 

A 

Ventricular  waves  initial    .        . 

/or/ 

R 

V 

Ventricular  waves  final      .        . 

F 

T 

V" 

Negative  waves  — 

After  auricular   .... 

Ap 

After  ventricular  post-initial 

Iporjf 

S 

After  ventricular  post-final          . 

FP 

Before  ventricular  initial    . 

la  or  Ja 

Q 

Before  ventricular  final 

Fa 

Time  of  passage  in  His's  bundle 

A 

Time  of  passage  in  heart  wall    . 

t  or  w 

Pause  of  Heart  .        .         . 

P 

This  diagram  is  copied  from  Kraus  and 
Nicolai's  Das  Elektro  Kardiogramm,  p.  201,  but  7, 
the  first  letter  of  "  initial,"  has  been  substituted 
for  /,  and  w,  the  first  letter  of  "  wall  of  heart," 
for  /,  the  first  letter  of  "  Treibwerk." 

By  means  of  this  instrument  it  is  possible  to 
settle  many  questions  regarding  the  heart.  By 
its  means  the  occurrence  of  fibrillation  of  the 
auricles  has  been  demonstrated,  and  Fig.  50 


COAGULABILITY  OF  THE  BLOOD       145 

shows  that  stimulation  of  the  vagi  lengthens 
the  time  required  for  a  stimulus  to  pass  from 
the  auricle  to  the  ventricle  ^ 

Coagulability  of  the  Blood. — Stoppage  of  the 
circulation  through  an  artery  by  coagulation 
of  the  blood  within  it  gives  rise  to  the  same 
symptoms  as  arrest  of  the  circulation  from  any 
other  cause,  and  when  it  occurs  in  one  of  the 
vessels  of  the  brain  it  is  sometimes  exceedingly 
difficult  to  diagnose  between  bursting  of  a  vessel 


FIG.  50.— Electro-cardiogram  during  irritation  of  the  vagus.  E.G.  ia  the 
electro-cardiogram.  Vent,  is  a  tracing  taken  mechanically  from  the 
ventricle,  and  A  ur.  one  from  the  auricles.  The  upright  dotted  line 
shows  the  moment  at  which  the  stimulus  is  applied  to  the  vagus. 
The  time  which  elapses  between  the  auricular  variation  and  beat  and 
those  of  the  ventricle  is  exceedingly  short  before  stimulation,  and  very 
long  during  it.  (After  Eraus  and  Nicolai.) 

and  consequent  haemorrhage  and  thrombosis. 
One  of  the  important  diagnostic  points  is,  of 
course,  arterial  tension,  because  with  a  high 
arterial  tension,  hemiplegia,  monoplegia,  or 
aphasia  are  probably  due  to  haemorrhage ; 
while  if  the  tension  is  low,  they  are  probably 
due  to  thrombosis.  An  additional  means  of  diag- 
nosis is  the  rapidity  with  which  the  blood  coag- 
ulates. A  good  method  of  ascertaining  this  is 
Wright's.23  It  consists  of  a  series  of  fine  tubes 
into  which  the  blood  is  drawn  from  a  puncture 
in  the  finger.  They  are  then  placed  in  water 


146    EXAMINATION  OF  THE  CIRCULATION 

about  the  temperature  of  the  body.  At  varying 
intervals  one  blows  down  the  tube  and  the  time  is 
noted  when  the  blood  can  no  longer  be  blown 
out.  This  indicates  the  time  of  coagulation, 
and  the  interval  between  this  and  the  rilling 
of  the  tube  is  the  coagulation  time.  It  varies 
under  different  circumstances,  a  fairly  average 
time  being  four  minutes.24 

Viscosity  of  the  Blood.  —  It  has  already 
been  mentioned  (p.  16)  that  the  arterial  pressure 
depends  upon  the  difference  in  quantity  between 
the  amount  of  blood  forced  into  the  aorta  by 
the  heart  and  the  amount  of  blood  which  runs 
out  into  the  veins  through  the  arterioles  and 
capillaries  in  the  same  time.  The  amount  of 
blood  which  thus  flows  out  from  the  arterial 
system  depends : 

1.  Upon  the  amount  of  pressure  in  the  aorta ; 

2.  On  the  size  of  the  efferent  arterioles  and 

capillaries ;  and 

3.  On  the  viscosity  of  the  blood. 

When  two  fluids,  one  of  which,  like  mucilage 
or  syrup,  is  viscous  and  the  other,  like  water,  is 
non-viscous,  are  forced  through  capillary  tubes 
of  equal  diameter  and  under  equal  pressures, 
the  viscous  fluid  will  flow  much  more  slowly 
through  the  tubes  than  the  non-viscous  one,  and 
the  slowness  of  its  flow  will  be  in  proportion  to 
its  viscosity.  The  first  experiments  on  the 
relationship  of  the  viscosity  of  a  fluid  to  its 
circulation  through  the  blood-vessels  were  made 
by  the  Rev.  Stephen  Hales25  (cf.  p.  15)  but  his 
experiments  were  very  imperfect.  Poiseuille28 
investigated  the  relationship  of  viscosity  to 


VISCOSITY  OF  THE  BLOOD  147 

rapidity  of  flow  in  a  very  complete  manner,  and 
the  subject  has  also  been  experimented  upon 
by  Matthews  Duncan  and  Gamgee,27  C.  A. 
Ewald,28  Haro,29  and  others. 

The  viscosity  of  the  blood  is  ascertained  by 
noting  the  rate  at  which  blood  will  flow  through 
the  capillary  tubes.  Several  instruments  of  this 
sort  are  described  by  Dr  Determann.30  The 
viscosity  is  increased  by  accumulation  of 
carbonic  acid  in  the  blood,  and  therefore  when 
the  blood  becomes  very  venous  it  will  flow 
with  difficulty.  Oxygenation  of  the  blood 
lessens  the  viscosity,  and  this  accelerates 
the  circulation. 

When  blood  would  not  flow  from  a  vein  after 
venesection,  I  have  found  the  inhalation  of 
oxygen  produce  a  free  flow  of  blood  almost 
immediately. 

Increased  viscosity  of  the  blood  as  a  cause  of 
high  arterial  tension  has  hitherto  received  little 
attention,  but  it  is  possible  that  future  researches 
may  show  it  to  be  an  important  factor  in  the 
production  of  this  condition. 

According  to  Haro,  the  flow  of  defibrinated 
blood  is  quickened  by  heat  and  by  oxygenation, 
but  is  slowed  to  a  remarkable  extent  by  bile 
salts. 


148  LITERATURE 


LITERATURE. 

I  Marey,  Physiologic  medicate  de  la  Circulation  du  Sang, 

1863  (Paris  :  Delahaye) ;  Mouvement  dans  la  Vie, 
1868  (Paris :  Bailliere) ;  Trauvaux  du  Laboratoire, 
Anne"e  1875-6,  p.  337  et  seq.  (Paris  :  Masson) ;  La 
Circulation  du  Sang  a  PEtat  physiologique,  etc., 
1 88 1  (Paris  :  Masson). 
8  Marey,  Circul.  du  Sang,  p.  117. 

3  Marey,  op.  tit.,  p.  618. 

4  Roy  and  Adami,  Practitioner,  1890,  vol.  xliv.,  p.  242. 
6  Marey,  Circul.  du  "Sang,  p.  152. 

6  Marey,  Physiol.  med.,  etc.,  1863,  P-  J7%  et  seq. 

7  Dudgeon,  London  Med.  Rec.,  1881,  p  400. 

8  A.  Jacquet,  Ztschr.  f.   Biol.,   1891,   vol.   xxviii.,   New 

Series,  vol.  x.,  p.  i. 

9  Kronecker,  -vide  Scholtyssek,  Arch.  f.  Anat.  u.  Physiol., 

phys.  Abtg.,  1909,  p.  326. 

10  Marey,  Circul.  du  Sang,  pp.  512  and  513. 

II  Lauder  Brunton,  Med.  Phys.  and  Circ.,  2nd  July  1879. 
12  James  Mackenzie,  Diseases  of  the  Heart,  pp.  69  and 

101  et  seg.,  1908  (London  :  Froude,  and  Hodder  & 
Stoughton). 

3  Tigerstedt,  Handb.  d.  Phys.,  p.  386. 
14  Marey,  Circul.  du  Sang,  p.  226,  with  literature,  1881 
(Masson:  Paris);  Waller,  Journ.  of  Physiol.,  August 
1880,  vol.  iii.,  p.  37,  and  Introduction  to  Human 
Physiol.,  p.  8,  1891  (London :  Longmans),  where  a 
figure  shows  at  a  glance  the  time-relations  of  the 
pulse  in  different  arteries. 

16  Vide  Hirschfelder,  Diseases  of  the  Heart,  p.  86,  for 

bibliography. 

18  Marey,  CircuL  du  Sang,  p.  26 ;  and  Travaux,  vol.  i., 
p.  47. 

17  Burdon-Sanderson    and     Page,   Journ.    of  Physiol., 

1879-80,  vol.  ii.,  p.  384  ;  ibid.,  1883,  vol.  iv.,  p.  327. 

18  Waller,  Journ.  of  Physiol.,  1887,  vol.  viii.,  p.  229. 

19  Einthoven,    Ann.    d.    Physik.,    1903,   Fourth    Series, 

vol.  xii.,  p.  1059  ;  Pfliiger's  Archiv,  1903,  vol.  xcix., 
p.  472  ;  and  other  papers  quoted  by  Kraus  and 
Nicolai. 


LITERATURE  OF  CHAPTER  VI         149 

20  Electro-cardiograms.     The  whole  subject  is  discussed 

at  length,  and  a  full  bibliography  given  by  F.  Kraus 
and  G.  Nicolai,  Das  Elektro  Kardiogramm,  1910 
(Leipzig  :  Veit  &  Co.). 

21  Kraus  and  Nicolai,  Das  Elektro  Kardiogramm,  p.  201  ; 

Nicolai,   Nagefs  Handb.  d,  Physiol.,  1909,  Bd.   i., 
p.  825. 
!2  Kraus  and  Nicolai,  op.  at.,  p.  147. 

23  Wright.     For  other  methods,  see  Sahli,  Lehrbuch  d. 

Untersuchungs  Methoden,  2nd  ed.,  622  et  seq.,  1899 
(Leipzig  and  Vienna  :  Deuticke). 

24  For  conditions  altering  the  rate  of  coagulation,  see 

S chafer  in  S chafer's  Textbook  of  Physiol.,  vol. 
i.,  p.  145  et  seq,  (Edinburgh  and  London,  1898). 

25  Stephen   Hales  Statical   Essays,  containing   Haema- 

staticks,  etc.,  vol.  ii.,  p.  143,  London.  Printed  for  W. 
Innys,  R.  Manby,  and  T.  Woodward,  1733. 

26  Poiseuille,  Me"m.  presents  par  divers  Savants  a  PAcad. 

de  Sciences,  1846,  vol.  ix.,  p.  514. 

27  Gamgee  and  Matthews  Duncan,  Journ.  of  Anat.  and 

Physiol.,  1871,  vol.  v.,  p.  155. 

28  C.  A.  Ewald,  Arch.  f.  Anat.  u.  Physiol.,  physiol.  Abtg., 

1877,  p.  208  etseq.;  ibid,,  1878,  p.  536. 

29  Haro,  Compt.  rend.,  1881,  vol  Ixxxiii.,  p.  696. 

30  Determann,  Die   Viscositdt  des  menschlichen  Blutes, 

1910  (Wiesbaden:  Bergmann). 


CHAPTER   VII 

PATHOLOGY  OF  THE  CIRCULATION 

Nutrition  of  the  Heart — Quality  of  Blood— Inflamma- 
tion —  Endocarditis  —  Pericarditis  —  Myocarditis — 
Fatty  Degeneration  —  Circulation  in  the  Heart — 
Blocking  of  Coronary  Arteries — Self-massage  of  the 
Heart  —  Nutrient  Action  of  Cardiac  Tonics — Self- 
massage  of  the  Arteries — Effect  of  Feebleness  of  the 
Heart  on  the  Nutrition  of  the  Blood-vessels — Feeble 
Pulse — Effect  of  Emotion  on  the  Vagus  Nerve — Ner- 
vous Depression — Fatty  Degeneration  —  Pulse-rate 
—Effect  of  Position  on  the  Pulse— Effect  of  Tempera- 
ture— Effect  of  Emotion — Tachycardia — Paroxysmal 
Tachycardia — Exophthalmic  Goitre — Bradycardia — 
Paroxysmal  Bradycardia — Stokes-Adams'  Syndrome 
— Intermittent  and  Irregular  Pulse — Coupled  Beats 
— Bigeminal  Pulse — Extra  Systoles — Pulsus  Para- 
doxus  and  Riegel's  Pulse. 

Nutrition  of  the  Heart. — The  power  of  the 
heart  to  contract  quickly  and  powerfully  depends, 
like  that  of  the  skeletal  muscles,  on  its  nutrition, 
and  this  is  regulated  to  a  great  extent  both  by 
the  quality  and  quantity  of  blood  it  receives. 
The  heart  is  like  the  priests  of  old,  who  took  the 
best  parts  of  the  offerings  before  the  remainder 
was  distributed  to  the  people.  For  the  coronary 
arteries  leave  the  aorta  just  above  the  sigmoid 
valves,  and  consequently  they  get  the  first 

150 


INFLAMMATION  OF  THE  HEART       151 

portion  of  blood  as  it  comes  fully  arterialised 
from  the  lungs,  and,  as  Sir  R.  Douglas  Powell 
has  pointed  out,  the  heart  is  more  dependent 
than  other  organs  upon  proper  pulmonary 
aeration. 

Quality  of  Blood. — Although  Kronecker  has 
shown  that  the  heart  may  beat  a  long  time 
without  any  fresh  supply  of  oxygen,1  yet  never- 
theless it  uses  up  oxygen  rapidly,  and  is  very 
sensitive  to  lessened  supply  of  oxygen.  In 
experiments  on  the  excised  mammalian  heart,  I 
have  seen  the  beats  become  feebler  as  soon  as 
the  oxygen  in  the  nutritive  fluid  became  less. 
It  is  even  more  sensitive  to  the  accumulation  of 
CO2,  and  if  this  is  not  removed  the  heart's  beats 
may  become  irregular,  occur  in  groups,  and 
finally  the  heart  stops  in  diastole.2  If  the  quality 
of  the  blood  is  bad  the  heart  suffers.  Thus,  fatty 
degeneration  of  the  heart  is  found  in  acute  and 
chronic  anaemia,  in  old  age,  in  failing  nutrition 
from  disease,  and  from  various  poisons,  e.g.,  in 
chronic  alcoholism,  or  after  the  administration 
of  chloroform,  arsenic,  or  phosphorus. 

Tnflfl.TnTna.tifm  of  the  Heart.  Endocarditis. 
Pericarditis.  Myocarditis. — The  common  cause 
of  inflammation,either  of  the  heart  or  pericardium, 
is  infection  by  some  pathogenic  microbe.  Endo- 
carditis occurs  most  frequently  in  connection  with 
rheumatic  fever,  which  is  probably  a  microbic 
disease,  although  a  microbe  has  not  certainly 
been  identified  with  it.  Other  microbes  which 
commonly  cause  it  are  various  kinds  of  cocci 
and  bacilli.3  The  inflammation  of  the  endo- 
cardium which  they  produce  may  lead  to  vegeta- 


152    PATHOLOGY  OF  THE  CIRCULATION 

tionsonthe  valves, and  consequent  incompetence, 
and  in  the  pericardium  may  produce  effusion  or 
lead  to  adhesions.  The  bacteria  probably  act  not 
only  mechanically  by  their  presence  in  the  tissues, 
but  by,  the  ferments  they  excrete  and  the  toxins 
they  produce.  Some  of  them,  especially  the 
microbes  of  diphtheria  and  influenza,  seem  to 
have  a  special  power  of  weakening  the  myocar- 
dium and  sometimes  paralysing  the  vagus.  The 
muscular  fibres  of  the  heart  become  changed 
by  the  prolonged  action  of  toxins,  and  undergo 
fatty  or  fibrous  degeneration  with  consequent 
weakening  of  their  contractile  power. 

Frequent  causes  are  the  toxins  which  occur 
in  various  diseases,  especially  those  of  the  in- 
fective fevers.  Sometimes  these  toxins,  instead 
of  producing  fatty  degeneration,  cause  a  general 
softening  of  the  muscular  tissues,  or  parenchy- 
matous  degeneration,  in  which  the  muscular  cells 
become  degenerated  but  not  fatty. 

Circulation  in  the  Heart. — The  right  coronary 
artery  supplies  chiefly  the  right  side  of  the  heart, 
the  left  coronary  artery  supplies  the  left  auricle 
and  ventricle  and  also  part  of  the  right  ventricle. 
The  terminal  branches  of  the  two  coronary 
arteries  communicate,  but  not  freely  enough  to 
maintain  circulation  if  one  of  the  arteries  be 
closed,  although  no  doubt  differences  in  this 
respect  exist  in  different  animals,  and  probably 
in  different  men.4 

Blocking  of  Coronary  Arteries. — When  the 
circulation  in  the  heart  is  suddenly  obstructed 
by  ligature  or  embolism  of  the  coronary  arteries 
the  heart  ceases  to  beat,  but  the  mode  in  which 


BLOCKING  OF  CORONARY  ARTERIES  153 

it  does  so  differs  according  to  the  nature  of  the 
obstruction.5  If  the  coronary  artery  is  ligatured, 
the  ventricle  stops  in  a  state  of  fibrillation.  If 
the  vein  is  ligatured  the  ventricle  stops,  but  there 
is  no  fibrillation.  If  embolism  is  produced  by 
the  injection  of  melted  paraffin  into  either  the 
whole  coronary  arteries  or  into  their  peripheral 
branches,  fibrillation  occurs ;  but  it  does  not  do 
so  if  the  injection  is  made  only  into  the  trunk 
of  the  coronary  arteries  and  prevented  by 
ligature  from  reaching  the  peripheral  branches. 
The  phenomenon  would  thus  seem  to  be  of  a 
reflex  nature,  arising  in  the  peripheral  vessels.6 
When  one  artery  is  closed  very  slowly  the 
communication  with  the  other  may  gradually 
become  sufficiently  increased  to  maintain  the 
circulation  after  the  first  has  become  completely 
occluded ;  and  the  vessels  of  Thebesius,  at 
least  in  the  dog,  may  maintain  the  circulation 
even  after  both  coronary  vessels  have  been 
obstructed.7 

Partial  blocking  of  a  branch  of  a  coronary 
artery  may  produce  a  local  necrosis  of  the 
cardiac  wall,  causing  either  sudden  death  or 
the  formation  of  a  fibrous  patch.8  When  the 
coronary  arteries  undergo  gradual  closure,  the 
muscular  tissue  they  supply  undergoes  either 
fibrous  change  or  fatty  degeneration.  In  either 
case  the  heart  is  much  weakened ;  and  in 
chronic  valvular  disease,  as  also  in  old  people, 
brown  atrophy  is  common. 

If  one  artery  be  narrowed  by  atheroma,  that 
part  of  the  heart  which  it  ought  to  nourish  is 
apt  to  undergo  fatty  or  fibrous  degeneration, 

M 


154    PATHOLOGY  OF  THE  CIRCULATION 

and  one  can  readily  see  that,  even  if  the  artery 
remains  of  its  proper  size,  it  may  become  rela- 
tively too  small  for  a  heart  which  has  undergone 
hypertrophy. 

Self -massage  of  the  Heart.  Effect  of 
Feebleness  of  the  Heart  on  its  own  Nutrition. 
— In  speaking  of  the  venous  circulation  in  the 
limbs,  I  mentioned  that  the  muscular  move- 
ments tend  to  aid  the  return  of  venous  blood, 
arid  the  same  thing  occurs  in  the  heart ;  for 
during  diastole  the  arteries  are  filled  at  high 
pressure  with  blood  from  the  aorta,  and  at  the 
same  time  venous  blood  is  pressed  out  of  the 
coronary  vein.  The  same  thing  probably 
happens  also  with  regard  to  the  lymphatics, 
which  run  alongside  of  the  coronary  arteries. 

As  Brucke  mentioned  in  one  of  his  lectures, 
which  I  heard  in  Vienna  in  1867,  Purkinje  found 
that  the  pericardium  may  be  likened  to  a  bell- 
jar,  the  walls  of  which  are  more  or  less  rigid,  the 
pericardium  being  attached  to  the  tissues  all 
round  it.9  When  the  ventricle  contracts,  it 
tends  to  produce  a  vacuum  in  the  pericardium, 
and  thus  not  only  to  suck  blood  into  the  auricles, 
but  also  to  exert  suction  upon  the  ventricle 
itself,  and  thus  to  draw  plasma  from  the  blood- 
vessels into  the  cardiac  muscle,  and  also  lymph 
into  the  pericardial  space  (Fig.  51).  When  the 
heart  dilates  again  in  diastole  it  tends  to  press 
the  lymph  out  of  the  pericardium,  and  thus 
keeps  the  pericardium  always  moist,  without 
any  accumulation  of  fluid  occurring.  The  alter- 
nate contraction  and  dilatation  of  the  heart  thus 
keep  up  what  we  may  term  a  sort  of  self- 


massage,  by  which  both  the  circulation  of  blood 
and  of  lymph  in  and  around  it  are  properly 
maintained.  It  is  evident,  therefore,  from  what 
I  have  just  said,  that  the  maintenance  of  the 
heart's  nutrition  depends  greatly  upon  its  own 
activity,  and  this  is  a  point  of  extreme  practical 
importance. 

Nutritive  Action   of  Cardiac   Tonics. — We 
can  thus  see  that,  in  cases  where  the  nutrition 


a  „ 


(a)  (b) 

Fio.  51. — Diagram  of  Purkinje's  experiments,  (a)  Shows  the  heart  in 
diastole  with  full  ventricle  and  empty  auricle.  (6)  Shows  it  in 
systole  with  empty  ventricle  and  full  auricle.  In  both  figures  a  is 
the  auricle,  o  the  ventricle,  vc  the  vena  cava,  ao  the  aorta,  and  p  the 
pericardium. 

of  the  heart  is  failing,  drugs  which  stimulate  it 
to  increased  action  do  not  act  merely  tempor- 
arily as  cardiac  stimulants,  but  that  they  are 
really  at  the  same  time  cardiac  nutrients.  It  is 
because  of  this  fact  that  the  good  effects  which 
we  see  from  the  use  of  strychnine,  digitalis, 
strophanthus,  caffeine,  etc.,  in  cardiac  disease  do 
not  cease  when  the  drugs  are  withdrawn,  but 
may  continue  and  increase,  these  drugs  having 


156    PATHOLOGY  OF  THE  CIRCULATION 

given  a  temporary  increase  to  the  power  of  the 
cardiac  muscle  which  has  enabled  it  to  nourish 
itself  more  efficiently. 

Self -massage  of  the  Arteries. — A  very 
important  set  of  vessels  in  the  body  are  the 
vasa  vasorum,  the  blood-vessels  which  supply 
other  blood-vessels.  When  these  undergo 
change,  so  that  the  blood-vessels  themselves 
are  badly  nourished,  the  condition  of  the  circu- 
lation generally  becomes  very  precarious,  for 
there  is  a  great  deal  of  truth  in  the  old  saying, 
that  "  a  man  is  as  old  as  his  arteries."  When 


Pio.  52. — Artery  and  vein  in  common  sheath,  to  show  the  effect  of  the 
arterial  pulse  in  aiding  venous  circulation.  A,  artery  in  diastole. 
V,  distended  vein.  8,  common  sheath.  A',  artery  distended  by  the 
cardiac  systole.  V,  the  vein  compressed  and  partially  emptied  of 
blood. 

his  arteries  become  atheromatous  or  calcareous, 
the  termination  of  the  man's  life  is  not  likely  to 
be  very  far  off.  But  the  arteries  also  have  a 
power  of  self- massage.  The  hard  fibrous  tissue 
which  forms  their  sheath  usually  envelops  not 
only  the  artery  and  vein,  but  also  the  lym- 
phatics. Between  the  intima  and  media  of  the 
artery,  and  probably  in  the  media  itself,  there 
are  lymphatic  spaces,  and  in  the  adventitia 
there  are  distinct  lymphatic  vessels.  The 
alternate  distension  and  relaxation  of  the 
arterial  wall  at  each  pulsation  not  only  drive 
blood  and  lymph  towards  the  heart  at  each  beat 


SELF-MASSAGE  OF  ARTERIES         157 

of  the  heart,  but,  during  the  diastole,  as  the 
blood  runs  out  of  the  artery,  there  is  a  tendency 
for  the  arterial  coats  to  separate  from  one 
another,  and  thus  draw  in  fresh  supplies  of 
blood  into  the  vasa  vasorum,  and  of  plasma 
from  them  into  the  arterial  walls. 

Effect  of  Feebleness  of  the  Heart  on  the 
Nutrition  of  Blood-vessels. — From  what  I  have 
said  regarding  self-massage  of  the  arteries,  veins, 
and  lymphatics  within  their  common  fibrous 


FIG.  53.— Pulse  trading,  showing  the  effect  of  massage  and  graduated 
movements.  Bach  tracing  is  taken  partly  with  a  slow  and  partly 
with  a  quick  movement  of  the  sphygmograph.  The  upper  shows  high 
tension  and  a  feeble  heart ;  the  lower  shows  less  tension  and  a  stronger 
heart.  These  tracings  I  owe  to  the  kindness  of  Dr  Gustav  Hamel,  to 
whose  treatment  I  had  recommended  the  patient. 

sheath,  it  is  evident  that  smallness  of  the  pulse- 
wave  and  imperfect  expansion  of  the  artery  tends 
of  itself,  whether  it  be  due  to  feebleness  of  the 
heart,  high  tension,  or  rigidity  of  the  artery,  to 
lessen  the  massage  and  to  interfere  both  with 
the  nutrition  of  the  vessels  and  with  the  onward 
passage  of  venous  blood  and  lymph.  On  the 
other  hand,  if  the  alternate  dilatation  and  con- 
traction of  the  artery  at  each  pulse  be  extensive, 
as  in  the  lower  tracing,  the  self-massage  will  be 
well  effected  (Fig.  53).  Baths,  exercises,  general 


i $8    PATHOLOGY  OF  THE  CIRCULATION 

massage  and  drugs,  which  increase  the  amplitude 
of  the  pulse,  are  therefore  useful  aids  to  the 
nutrition  of  the  arteries.  Digitalis  and  its  con- 
geners increase  the  amplitude  of  the  pulse  by 
strengthening  and  slowing  the  heart ;  vascular 
dilators,  like  the  nitrites,  do  so  by  diminishing 
the  tensioa 

Feeble  Pulse. — The  chief  cause  of  feebleness 
of  the  pulse  is  weakness  of  the  heart,  and  this 
may  be  due  to  many  causes.  It  may  occur 
temporarily  from  want  of  food  or,  more  per- 
manently, from  disease  of  the  digestive  organs. 
The  heart  may  be  feeble  from  dilatation  or  from 
fatty  degeneration,  the  supply  of  blood  to  it 
may  be  lessened  by  mitral  obstruction,  or  its 
propulsive  action  on  the  blood  may  be  impaired 
by  mitral  regurgitation.  Or  its  beats  may  be 
weakened  by  over-action  of  the  inhibitory  nerves 
(vide  p.  64). 

Effect  of  Emotions  on  the  Vagus  Nerve. — 
One  common  and  important  cause  of  a  weak 
pulse  is  nervous  depression,  through  the  vagus 
nerve.  Nearly  all  the  emotions  can  be  expressed 
in  terms  of  this  nerve.  We  say  that  the  man's 
heart  sinks  within  him  for  fear  or  apprehension, 
it  beats  high  with  joy  or  hope,  he  sighs  for 
grief;  the  stomach  is  affected,  and  vomiting 
may  ensue  from  disgust ;  the  bowels  move  with 
compassion  ;  and  the  effect  upon  the  kidneys 
from  simple  excitement  is  well  known  to  all 
those  who  have  had  to  do  with  examinations. 

As  Gaskell  has  shown,  stimulation  of  the 
vagus  may  produce  slowing  of  the  heart's  action 
or  feebleness  of  action.  These  may  occur 


EFFECTS  OF  EMOTION  159 

separately  or  together,  and  this  probably  occurs 
also  from  depressing  emotions. 

On  one  occasion  I  was  feeling  the  pulse  of  a 
patient  in  whom  the  pulse-rate  was  usually  very 
steady.  The  pulse  was  72,  when  a  telegram 
was  brought  to  my  patient  announcing  the 
death  of  a  relative.  The  pulse-rate  at  once  fell 
to  66  and  continued  at  this  for  several  minutes, 
after  which  it  again  rose  to  72.  The  strength 
of  the  pulse,  as  far  as  I  could  detect,  remained 
unaltered. 

In  most  cases,  however,  I  believe  that  depress- 
ing emotions  affect  the  strength  rather  than  the 
rate  of  the  pulse.  The  effect  of  exciting 
emotions  is  described  at  p.  163. 

Nervous  Depression.  —  Nervous  depression 
from  emotional  causes  is,  I  believe,  a  much  more 
potent  factor  in  disease  of  the  circulation  than 
is  generally  recognised.  The  effect  of  grief, 
worry,  and  anxiety  upon  the  circulation, 
especially  in  elderly  people,  is  sometimes  very 
marked.  Not  long  ago  I  saw  a  man  whose 
heart  was  very  much  diseased  indeed,  as  shown 
by  physical  examination,  but  he  displayed 
wonderfully  few  symptoms  until  he  was  told 
the  actual  condition  of  his  circulation,  when  he 
seemed,  to  use  a  common  expression,  "  to  take 
it  to  heart,"  and  from  that  moment  he  went 
down  steadily  and  rapidly,  and  died  within  a 
few  days.  The  coincidence  was  very  marked, 
as  the  change  in  him  occurred  within  a  couple 
of  hours,  so  that  one  could  hardly  ascribe  it  to 
anything  else  than  nervous  depression.  Con- 
versely, hope  and  joy  are  most  potent  factors  in 


160    PA  THOLOG  Y  OF  THE  CIRCULA  TION 

stimulating  the  cardiac  action,  and  thus  increas- 
ing the  circulation  throughout  the  body,  and 
putting  into  action  all  those  subsidiary  aids  to 
the  nutrition  of  the  vessels,  and  the  return  of 
venous  blood  and  lymph,  of  which  I  have  already 
spoken. 

One  can  plainly  see  that  long-continued 
depression  of  the  heart's  action  by  grief  may 
bring  about  a  condition  of  malnutrition  with  no 
very  definite  organic  change  to  explain  it ; 
and  such  a  condition  is  indeed  frequently 
noticed,  not  only  in  the  old,  but  even  in  the 
young,  where  it  may  predispose  to  tuberculosis. 

Patty  Degeneration. — Another  very  frequent 
cause  of  weakened  cardiac  action  is  degenera- 
tion of  the  muscular  structure  itself,  fibrous  or 
fatty.  This  occurs  very  often  in  diphtheria, 
typhoid  fever,  and  other  infective  diseases 
(p.  152).  It  may  also  occur  from  altered 
nervous  supply ;  and  Eichhorst 10  observed 
fatty  degeneration  in  the  heart  of  fowls,  and 
Wassilieff11  in  that  of  rabbits,  after  section  of 
the  vagi.  Section  of  one  vagus  was  found  by 
Fantino  and  Timofeew12  to  produce  not  fatty 
but  atrophic  degeneration,  and  the  part  of  the 
heart  affected  varied  according  as  the  right  or 
left  vagus  was  divided.  Probably  the  great 
weakness  of  the  heart  after  diphtheria  is  due  in 
some  cases  to  a  triple  action,  viz.,  (r)  to  the 
effect  of  the  toxin  in  causing  degeneration  of 
the  cardiac  muscles;  and  (2)  to  its  causing 
degeneration  of  the  suprarenal  bodies ;  and  (3) 
to  its  effect  in  producing  paralysis  of  the  vagus 
nerves,  just  as  it  does  of  the  nerves  going  to 


PULSE-RATE  161 

the  pharynx.  This  paralysis  is  shown  by  the 
extreme  rapidity  of  the  pulse,  which  may  come 
on  during  the  height  of  the  disease  and  continue 
for  months  afterwards. 

Fatty  or  fibrous  degeneration  of  the  muscular 
fibres  naturally  produces  feeble  action  of  the 
heart,  and  such  degeneration  is  commonly 
consequent  upon  interference  with  the  circula- 
tion through  the  coronary  arteries.  Here  we 
must  distinguish  between  the  two  sides  of  the 
heart,  because  although  both  coronary  arteries 
may  be  affected,  yet  occasionally  we  find  one 
affected  and  not  the  other.  The  symptoms  due 
to  affection  of  the  two  sides  we  shall  have  to 
consider  later  on.  It  is  to  be  noted  that  some- 
times fatty  degeneration  may  occur  in  patches, 
affecting  the  trabeculae,  or  the  musculi  papil- 
lares.13  When  the  latter  are  affected  it  seems 
highly  probable  that  the  conduction  of  stimuli 
in  the  ventricle  may  be  impaired. 

Pulse-rate. — The  rate  of  the  pulse  depends 
on  many  factors.  In  disease  it  may  be  much 
affected  by  the  condition  of  the  heart  itself;  but 
in  health  it  is  regulated  chiefly  by  the  central 
nervous  system  through  the  cardiac  nerves,  and 
especially  by  the  vagi.  These  nerves  are  in  a 
state  of  tonic  action,  which  may  be  increased  or 
diminished  so  as  to  slow  the  pulse  or  quicken 
it.  Such  alterations  occur  from  reflex  stimuli 
arising  from  any  part  of  the  body,  but  the  tone 
is  maintained  to  a  great  extent  by  the  pressure 
of  blood  within  the  vessels  supplying  the  inhibi- 
tory centre  in  the  medulla.  When  the  tension 
within  these  vessels  rises,  this  centre  is  stimu- 


1 62    PATHOLOGY  OF  THE  CIRCULATION 

lated  and  the  pulse  slowed  ;  when  the  tension  is 
diminished,  the  centre  acts  more  feebly  and  the 
pulse  becomes  quicker.  In  consequence  of  this 
any  rise  in  the  blood- pressure  generally,  as  from 
exposure  to  cold  or  locally  from  position,  tends 
to  slow  the  pulse.14 

Effect  of  Position. — The  usual  pulse-rate  in 
man  is  sixty  to  eighty  per  minute  in  the  sitting 
position,  and  rather  quicker  in  women.  The 
effect  of  gravity  tends  to  make  the  blood  sink 
from  the  head  to  the  feet,  and  it  is  probably 
on  this  account  that  the  pulse  in  the  upright 
posture  is  usually  about  eight  beats  quicker, 
and  in  the  recumbent  position  about  four  beats 
slower  than  in  the  sitting  posture.15  These 
numbers  vary  much  in  different  persons,  and  in 
the  same  person  at  different  times  ;  but  usually 
there  is  a  difference  of  at  least  seven  beats 
between  lying  and  standing,  and  the  absence  of 
this  difference  has  been  regarded  by  Huchard 
as  evidence  of  the  rigidity  of  the  arteries.16 

When  the  head  is  brought  lower  than  the 
body  some  accelerating  mechanism  is  brought 
into  action,  for  I  have  found,  in  experiments  on 
myself,  that  while  my  pulse  conforms  to  the  rule 
in  sitting,  standing,  or  lying  down,  it  becomes 
much  quickened  if  I  lie  with  my  head  hanging 
down.  I  have  seen  the  same  condition  in  a  case 
of  cerebral  abscess,  where  the  pulse  was  very 
quick  before  the  operation,  but  fell  to  the  normal 
when  the  intracranial  pressure  was  removed  by 
trephining. 

Effect  of  Temperature. — Warmth  quickens 
the  pulse-rate,17  both  by  acting  directly  on  the 


AGENCIES  AFFECTING  PULSE-RATE   163 

heart18  and  by  dilating  the  vessels,  lowering  the 
blood-pressure,  and  thus  lessening  the  stimula- 
tion of  the  vagus  roots.19  Cold  has  an  exactly 
opposite  effect  on  the  heart  and  vessels,  and 
slows  the  pulse. 

In  fever  the  high  temperature  of  the  body 
quickens  the  pulse,  but  sometimes  other  factors, 
such  as  toxins,  may  modify  the  effect  of  tem- 
perature, so  that  in  typhoid  fever  the  pulse  is 
usually  much  slower  than  one  would  expect 
from  the  temperature. 

Effect  of  Emotion. — Emotions  may  quicken 
the  pulse  very  greatly,  and  in  nervous  people 
the  mere  excitement  of  consulting  a  doctor  may 
raise  the  pulse  to  100  beats  per  minute  or  more, 
while  at  the  same  time  it  may  greatly  increase 
the  force  as  well  as  the  rate  of  the  heart's  action 
(Fig.  54).  This  condition  usually  subsides 
quickly.  A  very  common  rate  of  pulse  is  76 
in  normal  conditions,  92  in  moderate  excite- 
ment or  slight  fever,  and  120  in  great  excite- 
ment or  high  fever. 

A  pulse  of  1 20  indicates  that  the  vagus  is 
not  acting,  for  this  rate  has  been  found  when 
the  vagus  has  been  paralysed  by  atropine.20  I 
have  seen  it  occur  more  or  less  permanently 
when  the  vagi  were  paralysed  after  diphtheria 
or  from  alcoholic  neuritis. 

Tachycardia. — After  very  severe  exercise  the 
heart  may  remain  quick  for  several  days.  A 
very  quick  pulse  without  obvious  cause  ought 
to  lead  to  careful  examination  for  myocarditis. 

Paroxysmal  Tachycardia. — This  is  a  con- 
dition in  which  the  pulse  becomes  suddenly 


164    PATHOLOGY  OF  THE  CIRCULATION 

quickened  to  twice,  thrice,  or  sometimes  nearly 
four  times  its  normal  rate,  from  70  to  140,  200 
or  280.  After  the  attacks,  which  are  usually 
associated  with  great  discomfort,  have  lasted 
for  a  varying  time  from  minutes  to  days,  they 
pass  off  as  suddenly  as  they  came.  The  exces- 
sive pulse-rate  shows  that  they  cannot  be  due 
to  paralysis  of  the  vagus  alone,  but  that  there  is 


Fio.  54. — Effect  of  excitement  on  the  pulse  of  a  nervous  boy  aged  15.  a  is 
a  tracing  taken  immediately  on  his  entering  the  consulting-room ; 
b  some  minutes  later,  when  his  agitation  was  passing  off. 

either  some  excitable  condition  of  the  heart 
itself  or  great  stimulation  of  the  accelerator 
nerves,  or  both.21  The  fact  that  they  can  fre- 
quently be  cut  short  by  an  emetic  appears  to 
indicate  that  reflex  stimulation  of  the  acceler- 
ators from  the  stomach  is  a  powerful  factor  in 
their  production.  At  the  same  time  there  is 
probably  some  predisposing  cause  in  the  heart 


TACHYCARDIA  165 

itself,  for  Lewis  has  produced  tachycardia 
experimentally  by  ligaturing  a  coronary  artery,22 
especially  the  right.  Electro-cardiograms  ob- 
tained during  an  attack  seem  to  show  the 
presence  of  auricular  fibrillation.  Very  few 
have  been  examined  after  death,  but  in  one-half 
of  them  interstitial  myocarditis  or  fatty  de- 
generation has  been  found. 

Exophthalmic  Goitre. — In  cases  of  exoph- 
thalmic goitre  the  internal  secretion  of  the 
thyroid  appears  not  only  to  quicken  the  heart 
but  to  dilate  the  vessels,  and  in  this  disease  the 
pulse  frequently  rises  to  130  or  140  beats  per 
minute,  or  even  more.  It  would  thus  appear 
that  not  only  is  the  vagus  paralysed,  but  that 
the  accelerators  are  stimulated.  This  effect 
upon  the  circulation  is  due,  at  least  to  a  con- 
siderable extent,  to  the  action  of  the  actual 
secretion  of  the  gland  itself,  for  I  have  seen  it 
occur  in  a  patient  with  myxcedema  who  took  thy- 
roid by  the  mouth  too  frequently  and  too  long. 

Bradycardia  or  Brachycardia. — This  is  just 
the  opposite  of  tachycardia.  In  some  people 
the  pulse  is  naturally  very  slow.  Napoleon's 
pulse  is  said  to  have  been  only  40  per  minute, 
and  in  a  fellow-student  of  mine  it  was  only  42. 

The  slow  pulse  may  be  either  apparent  or 
real.  In  some  cases  an  apparent  slowness  is 
due  to  the  fact  that  some  beats  of  the  heart  are 
so  feeble  that  the  ventricle  never  opens  the 
aortic  valves,  and  no  pulse  reaches  the  wrist. 
Sometimes  alternate  beats  are  weak  and  strong, 
so  that  for  a  heart  beating  eighty  times  per 
minute  only  forty  radial  pulses  are  felt23  (Fig. 


166    PATHOLOGY  OF  THE  CIRCULATION 

55).     In  other  cases  there  are  no  small   beats 
but  only  slow  pulsations. 

As  a  general  rule  bradycardia  is  probably  due 
most  frequently  to  excessive  action  of  the  inhibi- 
tory centres  in  the  medulla  or  in  the  heart  itself, 
and  their  action  may  be  increased  by  actual 
weakness  of  the  motor  apparatus  in  the  heart,  so 


Fio.  55. — Tracings  from  the  left  ventricle  and  aorta,  showing  a  slow 
pulse  in  the  aorta  due  to  each  alternate  beat  of  the  ventricle  being 
too  weak  to  overcome  the  pressure  within  the  aorta  and  lift  the 
aortic  valves.  The  upper  tracing,  VG,  is  from  the  left  ventricle. 
The  lower,  A,  is  from  the  aorta.  N  is  the  level  which  the  pressure 
within  the  ventricle  mast  attain  in  order  to  raise  the  aortic  valves. 
( After  Marey.) 

that  stimuli  are  either  slowly  generated  or  badly 
conducted. 

It  may  occur  from  central  stimulation  of  the 
vagus  by  high  arterial  tension  in  Bright's 
disease,  or  lead  -  poisoning ;  or  intracranial 
pressure  in  cerebral  tumour,  or  apoplexy ;  and 
by  chronic  inflammation,  as  in  general  paralysis. 
It  occurs  also  in  mental  affections,  as  mania  and 


BRAD  YCARDIA  167 

melancholia,  and  in  disease  or  injury  of  the 
medulla  itself  or  of  the  cervical  cord.  It  may 
be  caused  by  reflex  stimulation  of  the  vagus 
from  the  sexual  organs,  skin,  liver,  or  stomach, 
as  in  dyspepsia,24  gastric  ulcer,  or  cancer,  for 
reflex  stimulation  of  the  vagus  may  occur  from 
stimulation  of  any  sensory  nerve.25 

Heart-block  may  cause  it,  so  that  the  ventricles 
contract  only  once  for  every  three  or  four  beats 
of  the  auricles.26  Sometimes  the  inhibitory 
mechanism  in  the  heart  itself  may  be  excited 
by  irritation  of  the  vagus  trunks  or  branches  ot 
the  vagus  in  the  cardiac  plexus,  just  as  slowness 
of  the  pulse  may  be  produced  experimentally 
by  irritation  of  the  vagus  in  animals.  Slowness 
of  the  pulse  sometimes  occurs  in  women  after 
childbirth,  but  the  explanation  of  it  is  uncertain. 
It  is  very  apt  to  occur  when  the  heart  is  feeble, 
as  during  convalescence  from  infective  diseases, 
such  as  influenza,  acute  rheumatism,  diphtheria, 
pneumonia,  and  typhoid  fever ;  in  general 
weakness  due  to  anaemia,  chlorosis,  and 
diabetes ;  and  in  permanent  weakness  of  the 
cardiac  walls  due  to  fatty  or  fibroid  degenera- 
tion. It  is  seen  also  in  typhoid  fever  even 
while  the  temperature  is  high,  and  in  this  case 
it  is  probably  due  to  the  effect  of  a  toxin  which 
stimulates  the  inhibitory  mechanism  in  either 
the  medulla  or  the  heart,  and  prevents  the  pulse 
from  rising  above  80  to  96,  even  when  the 
temperature  would  lead  one  to  expect  a  pulse 
of  100  to  1 20.  In  the  convalescence  from  diph- 
theria the  slowness  of  the  pulse  is  not  improb- 
ably due  to  some  neuritis  of  the  vagus,  which, 


168    PATHOLOGY  OF  THE  CIRCULATION 

in  severe  cases,  leads  to  complete  paralysis  with 
exceedingly  rapid  pulse.  Other  poisons,  such 
as  those  which  occur  in  uraemia,  and  also  alcohol, 
coffee,  digitalis,  lead,  and  tobacco,  may  cause  a 
very  slow  pulse.  ,  It  is  frequent  in  jaundice,  and 
its  occurrence  here  appears  to  be  due  to  the  bile 
acids,  which  weaken  the  cardiac  muscle  and 
render  it  more  easily  affected  by  the  inhibitory 
nerves. 

Paroxysmal  Bradycardia. — In  this  affection 
the  pulse  suddenly  becomes  slow  and  usually 
small  and  weak.  This  condition  may  only  last 
for  a  few  minutes  or  may  continue  for  hours  or 
even  days,  and  then  passes  off  again  suddenly. 
It  is  usually  accompanied  by  coldness  and  pale- 
ness of  the  skin,  perspiration  and  feelings  of 
giddiness  and  faintness.  It  occurs  in  patients 
whose  hearts  are  enfeebled  by  infective  diseases, 
as  acute  rheumatism,  pneumonia,  and  especially 
influenza,  or  by  chronic  myocarditis,  fatty  heart 
or  sclerosis  of  the  coronary  arteries.  But  whilst 
these  conditions  predispose,  the  actual  attack  is 
probably  due  to  excessive  action  of  the  vagus, 
caused  by  some  reflex  irritation,  especially  from 
the  stomach  or  intestines.  Certain  poisons  give 
rise  to  it,  especially  tobacco,  and  sometimes 
coffee  or  tea,  though  these  latter  more  usually 
produce  tachycardia.27 

Stokes-Adams1  Syndrome. — This  consists  of 
extreme  bradycardia  (Fig.  56)  associated  with 
fainting  or  convulsions.  It  is  generally  due  to 
heart-block  associated  with  lesions  of  His's 
bundle,  but  the  attack  may  be  brought  on  by 
action  of  the  vagus.  The  two  factors  may  be 


IRREGULAR  PULSE  169 

separated  by  giving  atropine  (i  mgm.  =  -^  gr. 
troy).  This  paralyses  the  vagus  and  removes 
the  slowness  of  the  pulse  if  it  is  entirely  due  to 


PIG.  56. — Very  slow  pulse.    (Prom  a  Stokes- Adams  case.) 

the  vagus,  relieves  it  if  it  is  partially  due,  and 
does  not  affect  it  if  it  is  caused  entirely  by  heart- 
block.23 

Intermittent  and  Irregular  Pulse. — Inter- 
mission of  the  pulse  is  a  frequent  condition. 
In  it  one  beat  is  occasionally  dropped.  This 
may  happen  once  in  three  times,  so  that  2.  regu- 
lar beats  come  followed  by  a  pause,  or  it  may 
occur  after  4,  5,  or  more  beats  which  are  quite 
regular,  or  it  may  happen  at  irregular  intervals  ; 
for  example,  once  after  3,  next  time  after  5,  next 
after  7,  and  then  again  after  2.  A  condition 
very  like  that  of  imperfect  heart-block  was 
produced  by  Erlanger  in  his  experiments.29 

Coupled  Beats. — In  pulse  tracings  sometimes 
two  beats  occur  with  a  short  interval  between 
them,  the  second  being  followed  by  a  some- 
what longer  interval.  To  this  condition  the 
term  bigeminal  pulse  is  often  applied,  and  when 
the  interval  occurs  after  three  or  four  beats 
they  are  called  trigeminal  or  quartogeminal. 
Wenckebach  objects  to  the  term  as  misleading, 
and  would  discard  it  in*  favour  of  the  term  extra 

N 


systole.  It  occurs  in  cases  of  poisoning  by 
digitalis  or  tobacco.  The  irregularity  from 
tobacco  is  sometimes  very  extraordinary :  one 
slow,  strong  beat  followed  by  a  number  of  very 
quick  ones. 

This  condition  may  also  occur  quite  apart 
from  tobacco,  and  may  persist  for  many  years 
without  really  affecting  the  patient's  health. 
One  patient  of  mine,  who  is  now  seventy-nine 
years  of  age,  had  for  many  years  a  bigeminal 
pulse,  that  is,  two  beats  in  rapid  succession 
followed  by  a  longer  pause.  He  is  still  hale  and 
healthy.*  A  relative  of  my  own  died  at  the 
age  of  eighty-four,  after  having  had  a  very 
irregular  pulse  for  sixty -seven  years.  This 
irregularity  of  the  pulse  came  on  after  an 
attack  of  rheumatic  fever  at  the  age  of 
seventeen,  and  continued  all  the  rest  of  her 
life.  It  is  impossible  to  give  with  certainty 
any  explanation  of  the  exact  cause  of  these 
forms  of  irregularity.  Some  of  them,  such  as 
irregular  bradycardia  or  occasional  intermission 
of  a  beat,  appear  to  be  due  to  heart-block. 

Bigeminal  Pulse.  —  Bigeminal  pulse  may 
sometimes  occur  without  any  other  apparent 
cause  than  nervousness,  as  is  shown  by  the 
tracings  which  I  here  append,  where  the  pulse 
assumed  a  bigeminal  character  while  the 
sphygmograph  was  still  upon  the  wrist  and 

*  The  irregularity  came  on  in  1884.  My  tracings  of 
his  pulse  are  reproduced,  but  inaccurately,  in  my  article 
on  "Nervous  Diseases  of  the  Heart"  (Hare's  System  of 
Practical  Therapeutics  (Philadelphia  and  New  York^ 
2nd  ed.,  1901,  vol.  ii.,  p.  375)., 


EXTRA  SYSTOLES 


171 


between  the  taking  of  two  tracings.  There 
was  no  alteration  in  the  cardiac  dulness  and 
no  murmurs  were  present,  but  the  tension  was 
somewhat  low,  108.  I  have  here  used  the 
word  "bigeminal "  in  its  common  acceptation,  but 
the  subject  of  different  forms  of  it  has  been 
discussed  by  Lewis  in  his  book  on  the  Heart, 
p.  249.  Bigeminal  pulse  may  also  be  produced 
by  the  inhalation  of  nitrite  of  amyl. 

Extra  Systoles. — The  occurrence  of  ventri- 


Fio.  57. — Bigeminal  pulse  coming  on  while  the  sphygmograph  was  upon 
the  wrist.  The  upper  tracing  represents  the  normal.  The  second 
was  taken  almost  immediately  after  the  first.  There  was  no  apparent 
reason  for  the  alteration.  The  patient  was  a  youth,  aged  19,  suffering 
from  albuminuria.  Tension  108  mm. 

cular  extra-systoles  which  do  not  reach  the  pulse 
(vide  p.  165)  may  explain  many  cases  of  inter- 
mission and  irregularity ;  but  the  question  at 
once  arises,  What  causes  the  extra-systoles  ?  In 
experiments  on  mammals  they  are  usually  pro- 
duced by  electrical  or  mechanical  stimulation  of 
the  exposed  ventricle  itself,or  of  the  pericardium ; 
but  they  also  occur  in  a  heart  completely  isolated, 
artificially  perfused  if  the  pressure  is  suddenly 
raised  either  in  the  aorta  or  pulmonary  artery.30 


172    PATHOLOGY  OF  THE  CIRCULATION 

The  extra-systole  starts  from  the  left  ventricle 
when  the  outflow  from  the  aorta,  and  from  the 
right  ventricle  when  the  flow  from  the  pulmon- 
ary artery  is  stopped.31  At  present  it  is  im- 
possible to  be  sure  whether  this  result  is  due 
to  the  stimulus  of  pressure  acting  on  the  cardiac 
muscle  only,  or  also  on  the  cardio-motor  and 
inhibitory  mechanism  contained  in  it. 

In  man  the  heart  can  be  stopped  by  raising 
the  pressure  in  the  lungs,  and  thus  obstructing 
the  flow  through  the  pulmonary  vessels ;  as  in 
Valsalva's  experiment  by  forcible  expiration 
against  resistance.  Such  obstruction  will  occur, 
though  to  a  lesser  degree,  in  violent  coughing. 
The  tension  in  the  aorta  may  be  suddenly  raised 
by  any  violent  exertion,  and  as  the  breath  is 
frequently  held  in  straining,  pressure  may  be 
increased  in  both  ventricles. 

While  such  experiments  clearly  show  that 
irregularity  may  arise  from  conditions  affecting 
the  heart  alone,  without  intervention  of  the 
nervous  system,  it  must  be  remembered  that 
the  vagus  is  easily  stimulated  reflexly,  and  it  is 
possible  that  such  stimulation  may  aid  at  least 
in  production  of  intermittence.  I  think  a  true 
explanation  of  all  cases  of  irregularity  is  only 
obtainable  by  assuming  that  the  nervous  system 
also  affects  the  cardiac  rhythm,  and  that  some- 
times nervous  and  muscular  rhythms  interfere 
with  one  another.  In  Chapter  I.,  I  mentioned 
some  grounds  for  this  belief,  and  the  experi- 
ments by  von  Basch  and  Frohlich  tend  to  con- 
firm the  accuracy  of  my  views. 

Puiaus  Paradoxus  and  Riegel's  Pulse. — These 


LITERATURE  OF  CHAPTER  VII         173 

forms  of  irregularity  usually  indicate  pleuro-peri- 
cardial  adhesions,  which  probably  cause  tugging 
at  the  heart  during  respiration.  The  pulsus 
paradoxus  is  a  diminished  size  of  the  pulse  or 
dropping  of  a  beat  during  inspiration,32  whilst 
in  Riegel's  pulse  these  phenomena  occur  during 
expiration.33 


LITERATURE. 

1  Literature  by  Handler,  Zeitschr.f.  Biol.,  1890,  p.  233. 

2  Albanese,  Arch.  f.  exper.  Path.  u.  Pharm.,  1 893,  vol. 

xxxii.,  p.  302. 

3  Ziegler,  Lehrbuch  d.  Pathologischen  Anatomie,  8th  ed., 

vol.  ii.,  pp.  30  and  43  (Jena  :  Fischer,  1895). 

4  Baumgarten,  Amer.  Journ.  of  Physiol.,  1899,  vol.  ii., 

p.  251. 

5  Old  literature  regarding  ligature  of  a  coronary  artery 

is  given  by  W.  T.  Porter,  Journ.  of  PhysioL,  1894, 
vol.  xv.,  p.  120  et  seq.;  also  by  Tigerstedt  in  his 
Lehrbuch,  p.  190.  See  also  Schafer's  Textbook  of 
Physiol.,  1900,  vol.  ii.,  p.  164  ;  and  Nicolai,  Nagets 
Handbuch.  d.  PhysioL,  1909,  vol.  i.,  p.  694. 
8  Kronecker,  Physiol.  Cong.  III.,  in  Bern,  1893. 

7  Pratt,  Amer.  Journ.  of  Physiol.,  1898,  vol.  i.,  p.  86. 

8  Baumgarten,  Amer.  Journ.  of  Physiol.,  1899,  vol.  ii., 

P-  243. 

9  Purkinje,  Breslau  Schles.  Gesellsch.   Uebersicht,  1843, 

p.  157  et  seq. 

10  Eichhorst,   Die    trophischen   Beziehungen  der  Nervi 

Vagi  zum  Herzmuskel,  p.  18  (Berlin,  1879). 

11  Wassilieff,  Ztschr.f.  klin.  Med.,  1881,  vol.  iii.,  p.  316. 

12  Fantino  and  Timofeew  quoted  by  Tigerstedt,  Lehrbuch, 

p.  257. 

13  Ziegler,  op.  cit.t  p.  36. 

14  For  experiments  and  literature  on  this  subject,  vide 

Tigerstedt,  op.  «'/.,  p.  300  et  seq.;  also,  Francois 
Franck,  Trav.  du  lad.  de  Marey,  1877,  v°l-  i»-i 
p.  276. 


174  LITERATURE 

15  Guy,  article  "  Pulse,"  in  Todd's  Cyclopaedia  of  Annt. 

and  Physiol.,  p.  185  et  seq.,  1852. 

16  Huchard,  Maladies  du   Caeur,  301^  ed.,  vol.  i.,  p.  90 

(Paris:  O.  Doin,  1899). 

17  Lauder  Brunton,  St  Bartholomews  Hospital  Reports, 

1871,  vol.  vii.,  p.  216  et  seq.  (the  older  literature  is 
given  here) ;  a\so,Joum.  of  Ana/,  and  Physiol.,  1876, 
vol.  x.,  p.  602. 

18  Gaskell,  Phil.  Trans.,  1882,  p.  993. 

19  Hewlett,  Heart,  vol.  ii.,  p.  237. 

20  von  Bezold  and  Bloebaum,  Untersuch.  a.  d.  Phys.  lab., 

Wiirzberg,  1867,  vol.  i.,  p.  i  et  seq. 

21  Martius,  Tachycardie  (Stuttgart,  1895) ;    Hirschfelder, 

Diseases  of  the  Heart  and  Aorta,  1910,  p.  572,  gives 
bibliography. 

22  Lewis,  Heart)  vol.  i.,  p.  98  et  seq.  (London,  1910). 

23  Marey,  Circul.  du  Sang,  p.  122  (Paris,  1881). 

24  Somerville,   with    commentary  by    Lauder    Brunton, 

Practitioner,  1876,  vol.  xvi.,  p.  186. 
26   Vide  Tigerstedt,  op.  cit.,  pp.  287,  288,  289. 

26  Gibson,  Nervous  Affections  of  the  Heart,  p.  61  (Edin- 

burgh :  Pentland,  1904) ;  Mackenzie,  Study  of  the 
Pulse,  pp.  97,  213,  288  (Edin.  and  London  :  Pent- 
land,  1902). 

27  Hirschfelder,  op.  cit.,  pp.  48  and  460. 

28  Osier,  Angina  Pectoris  and  Allied  States,  p.  70  et  seq. 

(New  York,  1897) ;  Hirschfelder, op.  cit.,  p.  460  ^/  seq. 

29  For  discussion  of  arhythmia,  its  varieties  and  causes, 

vide  Wenckebach,  Arhythmia  of  the  Heart,  trans- 
lated by  Snowball,  1904  (Green,  Edin.  and  London) ; 
J.  Mackenzie,  The  Study  of  the  Pulse,  1902  (Pentland, 
Edin.  and  London);  Vaquez,  Lcs  Arhytkmies,  1911 
(Bailliere  et  Fils,  Paris) ;  Lewis,  Mechanism  of  the 
Heart  Beat,  191 1  (Shaw  &  Sons,  London). 

80  Heidenhain,  Pfluger's  Archiv,  1872,  vol.  v.,  p.  143. 

81  H.  E.  Hering,  Pfluger's  Archiv,  1900,  vol.  Ixxxii.,  p.  r; 

Martin,  Phil.  Trans.,  1883,  vol.  clxxiv.  (2),  p.  213  ; 

Howell  and  Donaldson,  Phil.  Trans.,  1884,  vol.  clxxv., 

p   151. 

52  Griesinger,  vide  Hirschfelder,  op.  cit.,  2nd  ed.,  p.  604. 
33  Riegel,  Berlin  Win.  Wochenschr.,  1877,  Jg.  xiv.,  657. 


CHAPTER   VIII 

SYMPTOMS  OF   DISORDERED   CIRCULATION 

Palpitation  —  Effect  of  Position  on  Palpitation  —  Ab- 
dominal Pulsation — Throbbing  of  Arteries — Flushes 
of  Heat — Shock — Shock  in  Surgery — Shock  from 
Gastric  Disturbance — Syncope — Low  Blood-pressure 
—  Breathlessness  —  Headache  —  Migraine  —  Sensi- 
bility of  Arteries — Functional  Sensory— Functional 
Motor  Phenomena  —  Sensibility  of  the  Heart  — 
Pain  in  the  Cardiac  Region  —  Angina  Pectoris 
— Pathology  of  Angina  Pectoris  —  Claudication 
and  Angina  Pectoris  —  Views  of  Allen  Burns  — 
Views  of  Sir  Benjamin  Brodie — Angina  Abdominis — 
Cardiac  Dyspnoea — Raynaud's  Disease — Chilblains; 
Urticaria  ;  Angio-neurotic  (Edema  —  Atheroma  — 
High  Blood  -  pressure  —  Insomnia  —  Giddiness  — 
Senile  Rise  of  Pressure — Senile  Decay — Embolism 
and  Thrombosis. 

Palpitation. — Palpitation  of  the  heart  is  a 
very  troublesome  symptom,  and  its  causation  is 
very  obscure.  Sometimes  it  appears  to  be 
an  almost  purely  subjective  sensation,  as  the 
patient  has  a  sensation  of  the  heart  beating 
strongly,  yet  the  hand  applied  to  the  apex  beat 
does  not  perceive  anything  unusual.  In  other 
cases  the  force  of  the  apex  beat,  as  felt  by  the 
hand,  is  distinctly  increased.  I  have  noticed 
such  an  increase  take  place  in  animals  poisoned 

176 


i;6  DISORDERED  CIRCULATION 

by  digitalis.  In  my  thesis  on  the  action  of  this 
drug  I  discussed  the  mechanism  of  palpitation, 
and  arrived  at  the  conclusion  that  it  was  prob- 
ably due  to  increased  power  of  the  heart  in 
proportion  to  the  resistance  it  had  to  overcome, 
so  that  the  ventricular  contraction  occurred 
rapidly,  and  the  apex,  therefore,  struck  forcibly 
against  the  chest  wall.1  What  seems  to  con- 
firm this  opinion  is  the  fact  that  palpitation  is 
frequent  in  states  of  debility,  but  is  frequently, 
indeed  one  may  say  generally,  absent  when  the 
heart  is  hypertrophied  but  the  tension  is  high  ; 
so  that,  despite  its  abnormal  strength,  the  heart 
cannot  contract  quickly. 

Effect  of  Position  on  Palpitation.  —  One 
would  naturally  expect  that  a  constantly  re- 
curring rhythmic  blow  upon  the  heart  at  each 
pulsation  would  increase  its  action,  and,  as  a 
matter  of  fact,  this  appears  to  be  the  case.  The 
heart  is  a  mobile  organ  and  moves  considerably 
to  the  left  when  a  person  lies  on  that  side. 
The  apex,  therefore,  tends  to  strike  more 
forcibly  against  the  chest  wall,  and  as  the  effect 
of  this  is  similar  to  that  of  a  blow  on  the  heart 
at  each  beat,  many  people  are  unable  to  lie  on 
the  left  side  in  consequence  of  the  palpitation 
which  then  comes  on,  while  if  they  lie  on  their 
right  side  the  heart  rests  on  the  right  lung  as 
on  a  cushion,  and  they  become  quite  comfort- 
able. When  the  stomach  is  distended  by 
flatulence  it  tends  to  push  the  heart  up  and 
bring  its  apex  against  the  chest  wall,  with  the 
same  result  as  lying  on  the  left  side,  and  when 
the  flatulence  is  expelled  and  the  heart  resumes 


ABDOMINAL  PULSATION  177 

its  normal  position  the  palpitation  disappears 
(cf.  Fig.  73,  p.  226). 

Abdominal  Pulsation. — In  this  condition  the 
abdominal  aorta  throbs  violently,  so  much  so 
that  it  is  sometimes  visible  through  the 
abdominal  walls  and  gives  rise  to  the  suspicion 
of  aneurism.*  The  pulse  is,  however,  only 
forwards  and  not  lateral,  and  is  lessened  or 
removed  when  the  patient  leans  forward.  It  is 
in  all  probability  due  to  a  loss  of  tone  in  the 
abdominal  aorta  (p.  84),  and  frequently  occurs 
in  connection  with  some  irritation  in  the 
abdomen,  such  as  gastric  or  duodenal  ulcer. 

Throbbing  of  the  Arteries. — Similar  throbbing 
may  occur  in  the  carotid  and  subclavian  arteries, 
and  probably  other  arteries  also,  as  patients  not 
unfrequently  complain  of  throbbing  in  the  head 
or  extremities.  Such  throbbing  occurs  frequently 
in  connection  with  exophthalmic  goitre. 

"Plushes  of  Heat." — Sudden  sensations  of 
heat  are  a  very  common  symptom  in  women  at 
the  menopause.  They  are  sometimes  accom- 
panied by  visible  flushing,  but  sometimes  not. 
They  are  probably  dependent  upon  a  kind  of 
toxaemia  due  to  some  internal  secretion. 

Shock.  —  Another  important  condition  in 
which  both  heart  and  vessels  appear  to  be 
affected  is  that  of  shock.  Here  the  heart  may 
become  slow  and  feeble,  but  this  does  not 
appear  to  be  all,  for  the  general  depression  is 
out  of  proportion  even  to  the  feebleness  of  the 
heart's  action.  Shock  is  especially  apt  to  come 

*  Sir  James  Paget's  Clinical  Lectures,  p.  138  (London  : 
Longmans). 


178  DISORDERED  CIRCULATION 

on  from  a  blow  in  the  epigastrium,  and  Goltz,  in 
his  famous  experiment,  showed  that  if  a  frog  be 
suspended  in  the  upright  position  and  its  heart 
exposed,  a  blow  upon  the  intestines  has  a  two- 
fold action.2  It  (i)  stops  the  heart  reflexly 
through  the  vagus;  but  after  this  effect  has 
passed  off  (2)  the  heart  beats  again,  but  is 
empty,  and  sends  on  no  blood  into  the  vessels, 
because  the  blow  has  caused  dilatation  of  the 
abdominal  vessels,  and  all  the  blood  becomes 
stored  up  in  them,  so  that  none  reaches  the 
heart.3 

It  is  not  improbable  that  a  similar  effect  may 


FIG.  58. — Diagram  to  illustrate  Goltz's  experiments,  a,  Normal  heart 
in  the  upright  position;  b,  heart  in  same  position  after  shock;  c, 
heart  as  in  6,  but  in  recumbent  position,  showing  it  full,  so  as  to 
keep  up  circulation,  though  the  veins  are  still  dilated. 

occur  from  irritants  inside  the  stomach  or 
intestine.  When  large  quantities  of  alcohol 
have  been  swallowed  at  a  draught,  death  has 
occurred  almost  instantly,  and  the  mechanism 
of  its  production  was  probably  the  same  as  in 
Goltz's  experiment.  Severe  pain  from  irritation 
of  nerves  in  other  parts  of  the  body  may  stop 
the  heart,  but  under  ordinary  circumstances  it 
also  causes  contraction  of  the  abdominal  vessels, 
and  thus  keeps  up  the  blood-pressure  and 
maintains  the  circulation.4  If  the  pain  be  very 
excessive,  it  is  quite  possible  that  an  opposite 


SHOCK  179 

effect  may  be  produced,  and  thus  fatal  syncope 
may  ensue. 

Shock  in  Surgery. — In  surgical  operations  if 
anaesthesia  is  imperfect,  reflex  stoppage  of  the 
heart  may  occur  without  reflex  contraction  of 
the  vessels,  and  thus  fatal  shock  may  be  pro- 
duced, whilst  perfect  anaesthesia  would  have 
abolished  any  reflex  action  on  the  heart  as 
well  as  on  the  vessels,  and  thus  prevented 
any  danger.6 

Shock  from  Gastric  Disturbance.  —  A  very 
remarkable  case  of  shock  from  apparently  a  very 
slight  cause  occurred  in  one  of  my  patients.  He 
dined  late  and  had  some  wine,  which  possibly 
underwent  acetous  fermentation  in  the  stomach. 
About  two  hours  afterwards,  when  walking  round 
his  house  before  going  to  bed,  he  took  a  small 
quantity  of  whisky  and  aerated  water.  Immedi- 
ately he  felt  a  shock,  staggered,  and  would  have 
fallen  to  the  ground  had  he  not  been  supported 
by  a  servant  who  was  accompanying  him.  A 
medical  man  staying  in  the  house  who 
came  to  his  assistance  found  him  pale  and 
collapsed  looking,  and  his  pulse  beating  at  the 
rate  of  130  per  minute.  He  did  not  recover 
completely  for  two  or  three  hours,  and  marked 
improvement  only  occurred  after  the  administra- 
tion of  a  large  dose  of  sodium  bicarbonate, 
although  40  grains  of  bromide  had  been  given 
without  effect.  The  symptoms  were  precisely 
such  as  would  have  followed  a  blow  on  the 
epigastrium,  and  I  am  unable  to  account  for 
them  except  on  the  supposition  that  the  effer- 
vescence caused  by  the  aerated  water  sprayed  the 


i8o  DISORDERED  CIRCULATION 

acid  contents  of  the  stomach  all  over  its  internal 
surface,  while  at  the  same  time  evolution  of  gas 
may  have  added  the  stimulus  of  mechanical 
distension. 

Syncope. — The  remarkable  difference  between 
shock  and  syncope  is  that  usually  in  shock  the 
brain  remains  clear,  but  in  syncope  the  person 
becomes  suddenly  unconscious.  The  pathology 
of  syncope  has  not  been  thoroughly  made  out, 
but  it  appears  to  be  due  to  sudden  anaemia  of 
the  brain.  The  brain  requires  a  large  supply  of 
blood  when  it  is  functionally  active,  so  that  blood 
is  withdrawn  from  the  limbs,  and  they  become 
smaller.  This  is  shown  by  Mosso  with  the  aid 
of  the  plethysmograph.6  When  measured  by 
this  instrument,  the  volume  of  the  arm  was 
found  to  become  much  smaller  when  the  person 
thought  hard,  as  the  blood  required  by  the 
increased  functional  activity  of  the  brain  was 
withdrawn  from  the  arm.  When  the  body  is 
upright,  the  pressure  of  blood  in  the  brain  is  less, 
but  it  becomes  greater  when  the  head  is  lowered. 
The  recumbent  position  is  therefore  the  best  to 
restore  a  fainting  person,  and  the  tendency  to 
faint  may  sometimes  be  averted  by  placing  the 
head  on  the  hands  between  the  knees.  Before 
the  introduction  of  anaesthetics  it  was  a  frequent 
custom  to  perform  operations  in  a  state  of  syn- 
cope, which  was  induced  by  laying  the  patient 
flat  on  the  ground  for  a  short  time  and  then 
raising  him  very  suddenly  to  the  upright  position 
by  several  strong  men.7  A  curious  observation 
was  made  by  John  Hunter  on  the  flow  of  blood 
during  syncope.  In  a  lady  who  was  being  bled, 


SYNCOPE— LOW  BLOOD-PRESSURE     181 

the  blood  issued  from  the  vein  slowly  and  was 
black,  but  the  moment  she  fainted  the  blood 
rushed  out  quickly  and  became  of  a  bright  colour. 
This  phenomenon  is  exactly  what  is  seen  in  the 
condition  of  the  submaxillary  gland  when  its 
arterioles  dilate  on  irritation  of  the  chorda  tym- 
pani.  As  the  blood  from  the  veins  at  the  bend 
of  the  arm  comes  to  a  great  extent  through  the 
muscles,  we  are,  I  think,  justified  in  believing 
that,  in  some  cases  of  syncope  at  least,  the 
vessels  of  the  muscles  undergo  sudden  dilatation, 
and  thus  the  blood-pressure  becomes  enormously 
and  instantly  reduced8  (cf.  p.  17). 

At  the  same  time  the  tendency  to  faint  in  hot 
rooms  is  much  greater  in  women  than  in  men, 
yet  in  men  the  muscular  area  of  vessels  is  larger 
and  in  women  the  splanchnic  area  (p.  19).  It 
seems  probable,  therefore,  that  splanchnic  dilata- 
tion may  cause  faintness  as  much  as  muscular. 

Low  Blood-pressure.9 — The  pressure  is  low 
in  shock  and  syncope,  in  collapse  from  poisons, 
in  severe  haemorrhage  or  profuse  discharges 
from  the  bowel  or  stomach,  as  in  diarrhoea, 
dysentery,  cholera,  or  continuous  vomiting.  It 
occurs  in  fevers  generally,  especially  typhoid, 
as  a  sequel  to  influenza  and  diphtheria,  in  fatty 
heart,  and  in  debility  from  chronic  diseases. 
Two  conditions  in  which  I  have  found  the 
tension  very  low  are  phthisis  and  excessive 
smoking.  An  abnormally  low  blood-pressure 
may  sometimes  be  a  precursor  of  phthisis,  and 
may  possibly  give  early  warning  of  danger.  In 
one  case  I  found  an  abnormally  low  pressure 
in  an  apparently  healthy  man  who  developed 


1 82  DISORDERED  CIRCULATION 

phthisis  several  months  afterwards.  One  of  the 
most  common  causes  of  low  blood-pressure  is 
excessive  smoking.  A  single  pipe  of  tobacco 
probably  raises  the  blood-pressure,  but  con- 
tinuous heavy  smoking  certainly  depresses  it. 
It  would  almost  seem  as  if  in  the  case  of  tobacco- 
smoking  anti-substances  were  generated  in  the 
body  which  more  than  counteracted  the  effect 
of  nicotine.  I  am  uncertain  how  far  this  lower- 
ing of  blood-pressure  is  due  to  dilatation  of  the 
vessels,  and  how  far  to  weakness  of  the  cardiac 
action.  On  account  of  its  effect  upon  the  heart  the 
smoking  must  be  regulated  to  a  certain  extent, 
but  at  the  same  time  I  am  rather  chary  of  asking 
heavy  smokers,  who  have  at  the  same  time  a  high 
blood-pressure,  to  give  up  smoking  entirely. 

Breathlessness. — In  breathlessness  of  cardiac 
origin  the  patient  is  often  free  from  any  dis- 
comfort when  at  rest,  but  any  exertion  brings  on 
an  attack.  In  this  condition  the  inspiration  is 
usually  quick,  but  expiration  is  much  pro- 
longed. Von  Basch  attributes  this  to  stiffness 
of  the  alveoli  in  the  lung,  so  that  they  fill  easily 
but  collapse  with  difficulty.  They  are  in  fact 
held  open  by  the  network  of  capillaries  which 
surrounds  them,  and  which  is  stiff  from  con- 
gestion.10 The  breathlessness  may  be  due  to 
backward  flow  of  blood  or  impeded  onward  flow 
in  mitral  regurgitation  or  obstruction,  or  to 
inability  of  the  right  ventricle  to  drive  the  blood 
against  resistance  in  emphysema  or  weakness 
of  the  right  ventricle  itself  from  dilatation  or 
fatty  degeneration  due  to  atheroma  of  the  right 
coronary  artery11  (p.  153). 


HEADACHE— MIGRAINE  183 

Headache. — Headache  is  a  common  symptom 
in  heart  disease.  In  patients  with  high  tension 
it  varies  from  a  dull  ache  to  excruciating  pain. 
It  is  usually  diffused  over  the  head,  but  it  may 
sometimes  be  localised  more  in  one  spot  than 
another,  e.g.  forehead  or  occiput,  and  may,  like 
ordinary  migraine,  be  accompanied  by  flashes 
of  light.  Curiously  enough,  there  is  sometimes 
little  or  no  recollection  of  pain,  though  it  may 
have  been  extremely  great  while  it  lasted. 

Migraine. — This  affection  occurs  quite  apart 
from  either  cardiac  disease  or  high  tension. 
The  pain  usually  affects  one  or  other  temple, 
and  is  frequently  brought  on  by  strain  of  the 
eyes  due  to  astigmatism  or  other  visual  defect. 
Its  pathology  is  very  interesting,  and,  I  think, 
throws  much  light  on  some  other  disorders  of 
the  circulation.  A  good  deal  of  discussion  has 
taken  place  in  regard  to  the  pathology  of  sick 
headache  or  migraine.  Du  Bois  -  Reymond 
described  the  temporal  artery  in  his  own  case  as 
being  much  contracted  during  the  headache,12 
and  therefore  concluded  this  was  a  general  con- 
dition ;  while  others  have  described  this  artery 
as  widely  dilated  and  throbbing,  and  have 
supposed  this  condition  to  be  constant.  I  have, 
unfortunately,  had  only  too  many  opportunities 
of  repeating  these  observations  on  my  own 
head,  and  I  have  found  that,  as  is  often  the  case, 
both  parties  are  right,  and  both  parties  are 
wrong ;  that  the  condition  described  by  each 
occurs,  but  that  it  does  not  extend  to  all  parts 
of  the  artery  at  the  same  time.  Sometimes, 
for  example,  during  a  fit  of  migraine  I  have 


1 84  DISORDERED  CIRCULATION 

found  my  temporal  artery  widely  dilated  and 
throbbing,  at  other  times  I  have  found  it  hard 
and  contracted,  like  a  piece  of  whipcord ;  but 
when  it  was  dilated,  if  I  followed  it  onward 
towards  the  periphery  I  ascertained  that  the 
ascending  temporal  branch  was  contracted  like  a 
bit  of  piano-wire  (Fig.  59,  c).  On  most  occasions, 
if  I  followed  the  contracted  temporal  artery 
backwards  towards  the  heart,  I  found  that  the 


FIG.  59. — Diagrams  of  the  carotid,  temporal,  and  occipital  arteries  in 
migraine,  a,  In  the  normal  state;  b,  during  migraine,  showing 
dilatation  of  the  carotid  and  spasmodic  contraction  of  the  temporal 
arteries ;  c,  during  migraine,  showing  dilatation  of  the  carotid  and 
temporal  arteries,  and  extreme  contraction  of  the  ascending  frontal 
branch  of  the  anterior  temporal  artery. 

carotid  on  that  side  appeared  to  be  as  thick  as 
my  thumb,  distended  to  three  times  its  normal 
diameter,  and  pulsating  violently.  The  con- 
clusion I  came  to,  therefore,  in  regard  to  the 
pathology  of  migraine,  is  that  there  is  peri- 
pheral contraction  and  central  dilatation  of  the 
arteries™ 

Sensitiveness  of  Arteries.  —  Arteries  are 
sensitive,  as  was  known  in  olden  days  before 
the  introduction  of  anaesthetics,  because  patients 
complained  of  pain  when  the  arteries  were 


SENSITIVENESS  OF  ARTERIES         185 

ligatured.  That  the  pain  in  migraine  is  to  a 
great  extent  due  to  the  stretching  action  exerted 
on  the  contracted  temporal  artery  by  the  blood 
which  tries  to  pour  into  it  from  the  dilated 
carotid,  is  shown  by  the  fact,  which  I  have 
proved  in  my  own  case,  that  if  pressure  be  ex- 
erted upon  the  carotid  so  as  to  stop  the  pulse 
in  the  temporal  artery,  the  headache  will 
frequently  disappear  instantly.  Unfortunately, 
however,  it  is  almost  impossible  to  compress 
the  carotid  without  also  pressing  upon  the 
vagus,  and  the  sense  of  oppression  on  the  chest 
which  this  produces  is  so  great  that  one  is 
generally  obliged  to  cease  compression  after 
a  few  seconds,  although  the  moment  the  finger 
is  removed  the  pain  in  the  head  comes  back 
with  a  rush  of  peculiar  intensity.  Megrim  is 
often  regarded  as  a  neuralgic  condition,  but  the 
observations  upon  my  own  head  which  I  have 
just  detailed  have  convinced  me  that,  although 
the  vascular  disturbance  which  occurs  in  it  is 
almost  certainly  due  to  an  altered  action  of  the 
vaso-motor  nerves,  yet  the  pain  is  to  a  great 
extent  like  that  of  colic,  where  we  find  intense 
pain  due  to  spasmodic  contraction  of  one  part 
of  the  intestine  with  dilatation  or  distension  of 
another. 

Functional  Sensory  Phenomena.  —  If  we 
assume  that  the  arteries  inside  the  cranium 
contract  in  the  same  way  as  outside,  it  is  easy 
to  understand  the  curious  nervous  symptoms 
that  often  accompany  migraine.  Thus,  if  the 
artery  to  the  visual  centre  be  contracted  there 
will  be  flashes  of  light,  zigzags,  or  hemianopsia. 

O 


1 86  DISORDERED  CIRCULATION 

Similar  contraction  of  the  arteries  supplying  the 
auditory,  olfactory,  or  gustatory  centres  may 
cause  disturbances  of  the  corresponding  senses.14 

Functional  Motor  Disturbances.  —  The 
functions  of  the  cerebral  motor  centres  may 
be  temporarily  abolished  by  a  spasm  of  the 
arteries  going  to  them  cutting  off  their  supply 
of  blood.  This  was,  I  believe,  first  recognised 
by  Professor  Emil  du  Bois  -  Reymond,  who 
considered  epilepsy  and  migraine  to  differ  in 
degree  rather  than  in  kind.15  I  have  myself 
observed  cases  in  which  migraine  was  accom- 
panied by  aphasia,  and  Russell  has  described 
cases  of  temporary  hemiplegia  probably  due 
to  arterial  spasm.16  In  some  cases  of  this  sort 
it  is  difficult  to  determine  how  much  is  due  to 
spasm  and  how  much  to  partial  obstruction  of 
an  artery  by  atheroma  and  possibly  thrombosis. 

Sensitiveness  of  the  Heart.  —  Like  the 
vessels,  the  heart  is  probably  sensitive  and 
capable  of  originating  pain  of  a  most  intense 
character.17  Pressure  from  the  outside  is  not 
felt,  as  Harvey  discovered  in  the  case  of  young 
Lord  Montgomery,  in  whom  a  congenital  defect 
of  the  sternum  exposed  the  heart.18  But  pressure 
from  without,  unless  very  excessive,  does  not 
produce  pain  in  hollow  muscular  organs  such 
as  the  stomach,  intestines,  urinary  bladder, 
gall-bladder,  gall-duct,  or  ureter ;  yet  distension 
from  within  causes  pain  of  the  most  intense 
character  in  all  these  organs.  They  are  all 
liable  to  discomfort  without  pain,  and  the  heart, 
too,  frequently  feels  discomfort  without  pain. 
The  sense  of  oppression  which  is  felt  from  grief 


PAIN  IN  CARDIAC  REGION  187 

or  anxiety  is,  I  think,  due  to  the  effect  of  the 
vagus  nerve,  because  I  have  noticed  in  my  own 
case  that  grief  has  produced  a  sensation  of 
oppression  in  the  chest  which  has  persisted 
after  the  emotion  which  had  given  rise  to  it  had 
passed  away.  We  know  that  this  feeling  of 
oppression  can  be  produced  by  mechanical 
irritation  of  the  vagus,  for  Professor  Czermak 
had  a  small  exostosis  on  one  of  his  cervical 
vertebrae,  and  by  compressing  his  vagus  between 
it  and  his  ringer  he  was  able  to  stop  his  heart, 
but  the  pressure  at  the  same  time  caused  this 
feeling  of  oppression,  or,  as  he  termed  it, 
"Beklemmung"  in  the  chest*19 

Pain  in  the  Cardiac  Region. — The  two  chief 
seats  of  cardiac  pain  are  over  the  apex  and  mid- 
sternum.  In  all  probability  mid-sternal  pain  is 
more  closely  connected  with  the  condition  of 
the  aorta  and  irritation  of  the  sensory  nerves  in 
it,  while  pain  over  the  apex  may  be  connected 
with  some  irritation  in  the  cardiac  muscle  or  in 
the  pericardium,  but  it  frequently  occurs  quite 
independently  of  any  organic  disease  of  the  heart 
whatever.  When  I  was  a  house-physician  the 
cases  under  my  observation  were  generally  of  a 
serious  nature,  and  in  them  pain  in  the  cardiac 
region  was  usually  associated  with  organic  heart 
disease,  or  else  with  inflammation  of  the  pleura. 

*  When  Professor  Czermak  described  this  feeling  he 
supposed  that  the  vagus  was  compressed  between  his 
finger  and  an  enlarged  gland,  but  I  was  informed  by  the 
late  Professor  Sharpey  that  what  Czermak  supposed  to 
be  a  gland  was  afterwards  discovered  to  be  an  exostosis 
on  one  of  the  cervical  vertebrae. 


1 88  DISORDERED  CIRCULATION 

When  I  began  to  see  an  enormous  number 
of  out-patients  at  St  Bartholomew's  Hospital 
(600-800  in  a  week),  I  at  first  carefully  examined 
the  heart  in  cases  where  complaint  was  made  of 
pain  over  the  apex  ;  I  soon  found,  however,  that 
in  the  great  majority  of  these  cases  there  was 
nothing  the  matter  with  the  heart  at  all,  and  in 
women,  especially,  it  was  generally  associated 
with  leucorrhcea.  How  far  this  condition  is 
due  to  a  nervous  connection  between  the  pelvic 
organs  and  the  heart,  and  how  far  it  may  be 
due  to  some  alteration  in  the  condition  of  the 
blood  consequent  upon  the  discharge,  I  cannot 
say,  but  under  treatment  by  iron  the  pain 
generally  subsided  in  a  very  short  time. 

Angina  Pectoris. — One  of  the  most  distress- 
ing forms  of  cardiac  disturbance  is  angina 
pectoris.  In  it  there  are  frequently  two  sensa- 
tions, or  perhaps  even  more :  one  of  intense 
oppression,  and  one  of  extreme  pain.  That  of 
extreme  pain  I  am  inclined  to  regard  as  similar 
to  colic  in  the  intestine,  and  as  depending  upon 
spasmodic  contraction  of  the  heart  against 
resistance  which  it  cannot  properly  overcome.20 
In  many  cases  this  is  situated  about  mid- 
sternum,  but  it  is  frequently  felt  more  towards 
the  cardiac  apex,  and  often  radiates  towards  the 
shoulders  and  down  the  arms,  especially  the 
left  arm.21  As  I  have  already  said,  it  is  probably 
due  to  a  want  of  relationship  between  the  power 
of  the  cardiac  muscle  and  the  resistance  it  has 
to  overcome.  It  is  brought  on  by  anything 
that  raises  the  blood-pressure  quickly,  such  as 
exertion  or  emotion,  and  especially  by  the 


ANGINA  PECTOR1S  189 

emotion  of  anger,  which,  as  in  John  Hunter's 
case,  may  bring  about  a  fatal  attack  at  once. 
Anything  that  interferes  with  the  action  of  the 
heart  tends  to  increase  the  pain,  and  thus  dis- 
tension of  the  stomach  by  tilting  the.  heart  up 
makes  the  patient  worse,  and  much  relief  is 
afforded  by  the  administration  of  carminatives, 
which  bring  the  flatulence  away  and  allow  the 
heart  to  resume  its  normal  condition.  I  have 
had  an  opportunity  of  watching  a  case  of  severe 
angina  pectoris  daily  for  many  weeks,  and  have 
been  able  to  satisfy  myself  that  although  rise  of 
tension,  quick  pulse,  and  cardiac  pain  usually 
came  on  together,  yet  each  might  occur 
separately  without  the  others.  A  feeling  of 
anxiety  often  accompanied  the  pain,  but 
anxiety  might  occur  without  pain,  and  vice 
versa. 

Pathology  of  Angina  Pectoris. — The  pain 
is  so  acute  as  to  resemble  neuralgia,  and  so  it 
has  been  regarded  by  some  writers  as  neuralgia 
of  the  heart.  From  observations  which  I  had 
an  opportunity  of  making  in  1867  I  came  to  the 
conclusion  that  it  was  due  to  spasmodic  efforts 
of  the  heart  to  contract  against  a  resistance 
which  was  too  great  for  it ;  that  in  fact  the  pain 
was  similar  to  that  felt  in  the  bladder  when  it 
is  trying  in  vain  to  empty  itself  in  face  of 
the  resistance  of  an  enlarged  prostate.  The 
resemblance  is  rendered  all  the  more  striking 
by  the  fact  that  in  both  cases  when  the  resist- 
ance is  removed  the  pain  disappears.  It  is  not 
mere  distension  which  causes  pain  in  either  case 
for  the  bladder  may  become  enormously  dis- 


190  DISORDERED  CIRCULATION 

tended  and  yet  no  pain  be  felt  until  it  tries  to 
contract  and  empty  itself,  and  great  dilatation 
of  either  ventricle  may  occur  without  pain. 
Even  patients  suffering  from  angina  pectoris 
are,  except  in  very  severe  cases,  free  from  pain 
when  they  are  at  rest,  and  it  is  only  when  they 
attempt  to  make  some  exertion  or  are  affected 
by  some  emotion  that  pain  comes  on.  Both 
exertion  and  emotion  raise  the  blood-pressure, 
and  it  is  especially  after  a  meal,  when  they  have 
this  power  to  a  greater  extent  than  during 
fasting,  that  they  bring  on  pain  most  easily. 
An  attempt  to  walk  uphill  is  one  of  the  com- 
monest causes,  and  if  it  be  made  immediately 
after  a  full  meal  the  attack  may  be  very  severe. 
In  slighter  cases  the  pain  ceases  when  the 
exertion  is  stopped,  and  if  exercise  is  begun 
very  slowly  it  may  not  come  on  at  all.  If 
exercise  is  carefully  continued  after  the  first 
pain  is  over  it  may  be  taken  to  a  very  con- 
siderable extent  without  bringing  on  the  pain 
again.  One  of  my  patients  expressed  to  me 
his  great  astonishment  that  although  a  step  or 
two  uphill  would  bring  on  the  pain,  yet  after  it 
was  over  he  could  walk  over  his  fields  as  well  as 
many  healthy  men  much  younger  than  himself, 
shooting  partridges. 

Angina  pectoris  is  most  common  in  men 
beyond  middle  life,  in  whom  tension  is  higher 
than  normal ;  but  it  may  occur  in  men  whose 
tension  is  normal  or  even  below  normal.  But 
just  as  a  weight  that  would  be  nothing  to  a  man 
may  be  too  great  for  a  boy  to  lift,  so  a  tension 
below  normal  may  be  too  great  for  a  weak  heart, 


PULSE  IN  ANGINA  PECTOR1S          191 

In  some  cases  the  heart  does  not  seem  weak 
when  the  patient  is  quiet,  and  yet  it  is  unable 
to  meet  the  least  strain.  It  has  no  reserve 
power.  I  have  already  mentioned  that  the 
heart  is  very  dependent  on  a  free  supply  of 
oxygen  and  becomes  weak  if  this  is  not  fully 
supplied.  In  the  heart,  as  in  other  muscles,  this 
is  afforded  by  a  freer  supply  of  oxygenated 
blood  when  any  work  is  required  of  it.  But  if 
the  coronary  arteries  be  calcified  they  cannot 
dilate  to  supply  the  necessary  blood,  and  calcifi- 
cation of  the  coronary  arteries  is  the  morbid 
condition  most  common  in  angina  pectoris. 
Whether  the  same  spasmodic  contraction  which 
I  have  described  in  migraine  may  occur  in  the 
coronary  arteries  or  not  is  a  question  regarding 
which  we  have  no  information  ;  but  such  contrac- 
tion, if  it  existed,  would  almost  certainly  cause 
angina,  and  the  occurrence  of  vascular  spasm  in 
angina  abdominis  seems  to  show  the  possibility 
of  the  coronary  arteries  being  stimulated  to  con- 
traction by  a  sudden  rise  in  blood-pressure.  In 
some  cases  there  is  certainly  contraction  of  the 
arterioles  in  the  body  generally,  raising  the  ten- 
sion, though  observations  are  not  so  numerous 
as  one  would  like,  because  it  is  very  difficult  to 
make  observations  in  angina  pectoris.  When 
the  attack  comes  on,  the  apparatus  for  observa- 
tion is  generally  not  at  hand,  and  even  if  it  is 
one  is  so  much  taken  up  with  trying  to  relieve 
the  patient  that  one  does  not  care  to  trouble 
him  with  the  application  of  instruments.  In 
1866  and  1867  I  had  an  opportunity  of  making 
observations  in  a  case  of  angina  pectoris,  in 


192 


DISORDERED  CIRCULATION 


which  the  attacks  occurred  every  night  and 
lasted  two  or  three  hours.  During  the  attack 
the  pulse  was  very  rapid  and  the  arterioles  were 


Pio.  01. — During  angina. 


PIG.  62.— During  severe  anginal  pain. 


FIG.  68.—  Pain  partially  relieved  by  amyl-nitrite. 


PIG.  64.—  Pain  removed  by  amyl-nitrite. 


contracted,  as  is  shown  by  the  very  slow  fall  of 
the  arterial  tension  during  the  cardiac  diastole. 
But  even  with  everything  at  hand  I  only  once 
succeeded  in  making  an  observation,  and  that 


CLAUDICAT1ON 


193 


a  very  imperfect  one,  of  the  commencement  of 
an  attack,  which  showed  that  as  the  pain  came 
on  the  tension  rose.  I  was  able  to  make 
numerous  observations  regarding  the  end  of  an 
attack,  and  found  that  as  the  tension  fell  the 
pain  disappeared  (Figs.  63  and  67). 

Pain  very  like  that  of  angina  may  occur  in 


FIG.  66.— Pain  coming  on  at  1 ;  more  severe  at  2. 


Fio.  66.—  Anginal  attack  fully  established  ;  pain  very  severe. 


Fio.  67.—  Pain  relieved  by  amyl  -nitrite. 

healthy  persons  from  overstrain  in  gymnastic 
exercises,  sports,  or  Alpine  climbing,  from  dys- 
pepsia, or  over-smoking.  It  may  also  occur  in 
hysteria  or  Graves's  disease.  These  cases  would 
all  be  explained  by  the  occurrence  of  spasm  of 
the  coronary  vessels  such  as  occurs  in  migraine. 
Claudication  and  Angina  Pectoris.  Views  of 


194  DISORDERED  CIRCULATION 

Allen  Burns. — In  some  old  persons  whose 
arteries  have  become  contracted  and  rigid  a 
peculiar  inability  for  exertion  comes  on,  to  which 
the  name  of  claudication  has  been  given.  This 
condition,  which  has  been  observed  in  animals 
whose  arteries  become  ossified,  was  appar- 
ently produced  experimentally  by  Allen  Burns 
by  means  of  a  moderately  tight  ligature  round 
the  limb,  and  he  recognised  the  relationship 
between  ossification  of  the  coronary  arteries  as 
a  danger  to  life  on  exertion.  He  says,  "  When, 
therefore,  the  coronary  arteries  are  ossified  every 
agent  capable  of  increasing  the  action  of  the 
heart,  such  as  exercise,  passion,  and  ardent 
spirits,  must  be  a  source  of  danger."22  This 
view  of  the  pathology  of  angina  pectoris  is  the 
one  which  is  now  commonly  adopted,  but  it  may 
occur  without  disease  of  the  coronary  arteries.2* 

Views  of  Sir  Benjamin  Brodie. — Claudication 
has  been  so  well  described,  and  its  relation  to 
angina  pectoris  has  been  so  clearly  pointed  out 
by  Sir  Benjamin  Brodie  in  1846,  that  I  cannot 
do  better  than  quote  his  words. 

"Such  patients,"  he  said,  "walk  a  short  dis- 
tance very  well,  but  when  they  attempt  more 
than  this  the  muscles  seem  to  be  unequal  to 
the  task,  and  they  can  walk  no  further.  The 
muscles  are  not  absolutely  paralysed,  but  in  a 
stage  approaching  to  it.  The  cause  of  all  this 
is  sufficiently  obvious.  The  lower  limbs  require 
sometimes  a  larger  and  sometimes  a  smaller 
supply  of  blood.  During  exercise  a  larger  supply 
is  wanted  on  account  of  the  increased  action  of 
the  muscles ;  but,  the  arteries  being  ossified  or 


ANGINA  ABDOM1N1S  195 

obliterated,  and  thus  incapable  of  dilatation,  the 
increased  supply  cannot  be  obtained." 

"  This  state  of  things  is  not  peculiar  to  the 
lower  limbs.  Wherever  muscular  structures 
exist,  the  same  cause  will  produce  the  same 
effect.  Dr  Jenner  first,  and  Dr  Parry,  of  Bath, 
afterwards,  published  observations  which  were 
supposed  to  prove  that  the  disease  which  is 
usually  called  'angina  pectoris'  depends  on 
ossification  of  the  coronary  arteries.  .  .  .  When 
the  coronary  arteries  are  in  this  condition  they 
may  be  capable  of  admitting  a  moderate  supply 
of  blood  to  the  muscular  structure  of  the  heart , 
and  as  long  as  the  patient  makes  no  abnormal 
exertion,  the  circulation  goes  on  well  enough ; 
when,  however,  the  heart  is  excited  to  increased 
action,  whether  it  be  during  a  fit  of  passion,  or 
in  running,  or  walking  upstairs  or  lifting  weights, 
then  the  ossified  arteries  being  incapable  of 
expanding  so  as  to  let  in  the  additional  quantity 
of  blood  which  under  these  circumstances  is 
required,  its  action  stops  and  syncope  ensues; 
and  I  say  that  this  exactly  corresponds  to  the 
sense  of  weakness  and  want  of  muscular  power 
which  exists  in  persons  who  have  the  arteries  of 
the  legs  obstructed  or  ossified." 24 

Angina  Abdominis.  —  In  1899  I  described 
attacks  of  abdominal  pain  under  the  name  of 
"  headache  in  the  stomach,"  because  I  thought 
they  were  due  to  spasmodic  contraction  of  the 
intestinal  vessels  similar  to  that  in  headache 
(p.  I84).25  Baccelli  gave  the  name  of  angina 
abdominis  to  such  attacks,  and  Huchard  of 
angina  pectoris  pseudo-gastrique.26  Pal  found 


196  DISORDERED  CIRCULATION 

them  to  be  very  frequent  in  tabes,  and  frequently 
associated  with  true  angina  pectoris.27  In  1912 
Dr  Williams  and  I  described  a  case  which 
resembled  angina  pectoris  in  being  brought  on 
by  exertion  and  at  once  relieved  by  nitro- 
glycerin.  exactly  in  the  same  way  as  angina 
pectoris.28 

Cardiac  Dyspnoea. — The  left  ventricle  supplies 
the  nervous  system,  the  muscles,  and  the  viscera, 
and,  therefore,  any  interference  with  its  action 
is  indicated  more  or  less  by  symptoms  which 
may  be  referred  to  those  structures,  such  as 
giddiness,  feebleness,  or  pain  like  that  of  angina 
abdominis  already  mentioned,  or  actual  pain  in 
the  heart  itself  or  in  the  aorta.  The  right 
ventricle  supplies  the  lungs,  and  interference 
with  its  action  lessens  the  respiratory  power.  For 
if  the  blood  be  kept  away  from  the  air,  by  arrest 
of  the  pulmonary  circulation,  the  result  is  similar 
to  that  of  keeping  the  air  away  from  the 
blood  by  obstructing  the  air-passages.  I  think 
that  cardiac  dyspnoea  occasionally  coincides 
with  angina  pectoris,  but  does  not  always  do  so, 
and  great  dyspnoea  may  occur  without  any 
actual  pain.  In  some  cases,  at  least,  cardiac 
dyspnoea  depends,  like  angina  pectoris,  upon 
partial  obliteration  of  the  coronary  vessels,  and 
in  one  case  I  was  able  to  diagnose  atheroma  of 
the  coronary  artery  supplying  the  right  ventricle 
from  the  breathlessness  of  the  patient,  while  the 
lungs  were  clear  and  the  left  ventricle  was  strong 
and  active  as  shown  by  the  forcible  apex-beat. 
The  diagnosis  might  seem  to  be  rather  far 
fetched,  but  no  other  was  really  possible,  and 


RA  YNA  UD>S  DISEA  SE  \  97 

post-mortem  examination  proved  its  correct- 
ness.29 In  cases  of  cardiac  dyspnoea  coming 
on  in  sudden  attacks  the  lungs  appear  to  be 
affected  as  well,  and  apparently  both  the 
secretion  from  the  pulmonary  mucous  membrane 
and  the  muscular  fibre  of  the  bronchioles  may 
be  affected,  because  both  dry  rales  and  moist 
rales  are  heard  in  the  lungs. 

Raynaud's  Disease. — Temporary  contraction 
of  the  arteries  and  anaemia  of  the  tissues  occur 
in  a  disease  described  by  Raynaud,  and  which 
bears  his  name.30  In  this  disease  the  arteries 
contract  spasmodically,  and  I  have  seen,  first  of 
all  the  tips  of  the  fingers  become  cold,  bloodless, 
and  shrunken  like  the  fingers  of  a  corpse,  and 
this  condition  gradually  extend  up  the  hand 
in  the  course  of  five  or  ten  minutes.  Sometimes 
only  one  finger  is  affected,  sometimes  the  whole 
hand,  sometimes  the  toes,  the  tips  of  the  ears 
or  the  nose,  and  occasionally,  though  rarely,  the 
arms  and  legs.  The  internal  arteries  appear 
also  to  undergo  a  similar  contraction,  especially 
those  of  the  kidneys  and  brain,  because  this 
disease  is  frequently  associated  with  haemoglo- 
binuria  and  sometimes  with  epileptic  symptoms 
and  transient  hemiplegia.  The  condition  is 
very  much  like  what  occurs  after  immersion 
of  a  hand  in  very  cold  water,  and  just  as  after 
the  hand  has  been  withdrawn  it  usually  becomes 
swollen,  hot,  and  red,  so  the  extremities  after 
the  spasm  has  passed  off  in  Raynaud's  disease 
become  red  and  hot.  On  very  cold  days  we 
notice  that  even  in  a  healthy  person  the  white- 
ness of  the  skin,  which  indicates  both  arterial 


198  DISORDERED  CIRCULATION 

and  venous  contraction,  is  succeeded  by  arterial 
contraction  with  venous  dilatation,  so  that  the 
surface  becomes  blue  instead  of  white.  The 
same  thing  occurs  in  the  severer  cases  of 
Raynaud's  disease,  and  the  term  of  local 
asphyxia  has  been  given  to  the  condition. 
In  extremely  severe  cases  the  contraction  has 
led  to  complete  stoppage  of  the  blood-supply, 
and  consequent  gangrene,  like  that  which  occurs 
in  senile  degeneration  of  the  vessels. 

Chilblains,  Urticaria,  Anglo-neurotic  CEclema. 
— A  condition  which  is  very  much  allied  to 
this,  but  much  milder,  is  the  common  one  of 
chilblains.  Another  ailment  which  is  very 
troublesome  and  where  there  is  a  local  vascular 
dilatation  with  effusion  of  lymph,  is  urticaria. 
The  wheals  characteristic  of  this  complaint  are 
very  much  like  those  which  are  produced  by 
a  stinging  nettle.  They  may  occur  without 
visible  cause,  but  in  some  persons  with  an 
irritable  vascular  system  they  may  be  produced 
by  simply  scratching  the  skin,  so  that  the 
patient's  name  may  be  written  on  his  back 
with  the  finger-nail.  In  so-called  angio-neurotic 
oedema,  instead  of  mere  wheals  occurring,  the 
patient  may  become  affected  by  rapid  and 
intense  cedema  over  a  large  portion  of  the 
body.  I  have  seen  in  half  an  hour  one  side 
of  the  patient's  face  become  so  much  swelled 
that  the  left  eye  was  almost  closed,  and  the 
left  side  of  the  face  was  like  that  of  a  patient 
suffering  from  advanced  renal  dropsy,  whilst 
the  other  side  of  the  face  remained  perfectly 
healthy.  The  pathology  of  this  condition  has 


AT  HE  ROM  A  199 

not  been  made  out,  but  the  cause  of  the  trouble 
probably  is  that  there  are  toxic  substances  in 
the  blood,  for  urticarial  rashes  are  very  common 
after  the  injection  of  diphtheria  antitoxin,  and 
I  have  seen  universal  oedema,  resembling  that 
of  advanced  renal  dropsy,  brought  on  by  the 
injection  of  anti-streptococcic  serum.  The  one- 
sided character  of  the  affection  in  the  case  I 
have  just  mentioned  shows  that  the  nervous 
system  is  also  deeply  concerned  in  the  disease. 
Atheroma. — In  the  arteries,  as  in  the  heart, 
interference  with  the  blood-supply  causes  de- 
generation. In  one  form — the  nodular  form — 
there  is  inflammation  in  and  around  the  arterial 
coats  with  local  infiltration  about  the  vasa 
vasorum,  leading  to  spots  of  degeneration  and 
formation  of  an  atheromatous  button,  or  a  patch 
of  nodular  arterio-sclerosis.  In  old  people  the 
arterial  walls  become  stiff,  and  are  often  as 
rigid  as  pipe -stems  from  calcareous  deposit, 
while  the  tissue  underneath  the  intima  may 
break  up  and  form  rough  atheromatous  ulcers.31 
One  of  the  most  important  changes  of  all  is 
the  diffuse  arterio-sclerosis,  or,  as  Gull  and 
Sutton  call  it,  arterio-capillary  fibrosis,  in  which 
the  wall  becomes  thickened  from  a  deposit  of 
hyaline  tissue  between  the  muscular  and  the 
endothelial  coats.32  This  deposit,  which  is 
liable  to  occur  in  kidney  disease,  is  of  great 
importance,  because  a  lessening  of  the  lumen  oi 
the  arterioles  increases  the  peripheral  resist- 
ance, leads  to  hypertrophy  of  the  heart,  and  thus 
to  an  enormous  increase  in  blood-pressure,  with 
consequent  danger  of  rupture  and  apoplexy. 


200  DISORDERED  CIRCULATION 

High  Blood-pressure. — The  views  of  Gull  and 
Sutton  were  opposed  at  the  time  they  were  put 
forward  by  Dr  George  Johnson,33  who  held  that 
the  increased  tension  was  due  to  contraction  of 
arterioles  throughout  the  body,  often  accom- 
panied by  a  hypertrophy  of  their  muscular 
coat.  There  appears  now  to  be  a  considerable 
amount  of  evidence  that  although  thickening  of 
the  arteries  may  be  one  factor  in  the  production 
of  high  tension,  yet  much  of  it  is  due  to  contrac- 
tion of  the  arterioles  due  to  stimulation  of  their 
muscular  coats  by  toxins.  It  has  now  been 
demonstrated  that  high  arterial  tension  of  itself 
produces  atheromatous  changes  in  the  vessels, 
so  that  as  disease  advances  both  factors  may 
combine  to  raise  the  pressure.34 

Insomnia. — This  is  sometimes  very  distressing. 
In  natural  sleep  the  rapidity  of  circulation  in  the 
brain  is  lessened  and  its  functional  activity 
diminished.*36  The  lessened  circulation  is 
probably  due  to  lessened  blood-pressure  in 
the  brain36  or  from  contraction  of  the  carotid 
arteries  and  their  branches,  and  if  they  are  rigid 
and  their  contractile  power  be  lessened,37  or  if 
the  arterial  tension  be  so  high  that  they  cannot 
sufficiently  resist  it,  sleep  is  difficult  to  obtain. 

Giddiness. — This  is  a  very  common  symptom 
in  disordered  circulation  and  is  very  often 
associated  with  faintness.  Both  symptoms 
usually  indicate  imperfect  supply  of  blood  to 
the  brain,  but  they  may  come  on  under  very 

*  The  dendrons  of  neurons  are  amoeboid.  Ross 
Harrison,  quoted  by  Mott,  Brit.  Med.  Joum.,  Sept.  28, 
1912,  vol.  ii.,  p.  781. 


HIGH  BLOOD-PRESSURE  ioi 

different  conditions.  In  young  people  they 
are  usually  connected  with  temporary  weakness 
of  the  heart's  action  or  unusual  dilatation  of 
the  vessels,  causing  an  abnormally  low  blood- 
pressure.  In  elderly  people,  on  the  other  hand, 
giddiness  is  often  an  accompaniment  of  high 
blood  -  pressure,  but  probably  its  occurrence 
depends  less  on  the  tension  than  on  tempor 
arily  impaired  blood-supply  to  the  brain  from 
atheroma  and  contraction  of  its  vessels.  It  is 
much  more  apt  to  come  on  if  the  blood  is 
imperfectly  freed  from  toxins  on  account  of 
constipation  or  biliousness.  In  some  patients 
it  is  certainly  of  labyrinthine  origin  and  is 
frequently  accompanied  by  rushing  noises  in  the 
ear,  synchronous  with  the  pulse  and  probably 
depending  on  atheroma  of  the  arteries  of  the 
ear.  In  such  cases  a  sudden  movement  of  the 
head  may  cause  so  much  giddiness  as  to  make 
the  patient  fall.  A  tendency  to  atheroma  which 
at  first  only  causes  giddiness  may  subsequently 
affect  the  coronary  arteries  and  cause  angina. 

Senile  Rise  of  Pressure. — I  must  here  draw 
attention  to  one  condition  which  is  very 
common,  and  which  may  become  still  commoner 
as  increasing  medical  knowledge  regarding  the 
prevention  of  infective  disease  leads  to  prolonga- 
tion of  life.  In  all  men  with  advancing  years 
the  arteries  tend  to  lose  their  elasticity  and 
become  more  rigid.  The  time  at  which  this 
alteration  takes  place  varies  in  different  indi- 
viduals and  in  different  families,  and  the  saying 
is  a  particularly  true  one  that  "  a  man  is  as  old 
as  his  arteries,"  so  that  not  infrequently  we  find 

P 


202  DISORDERED  CIRCULATION 

strong  athletic  and  robust  families  who  are  not 
only  powerful,  both  physically  and  mentally,  but 
apparently  free  from  disease,  and  who  are  yet 
short-lived.  I  believe  that  these  lives  might 
frequently  be  lengthened  by  timely  attention  to 
the  condition  of  the  arteries,  more  especially  by 
measurement  of  the  blood-pressure,  and  adjust- 
ment of  work,  of  exercise,  and  of  food  to  the 
condition  that  is  found.  The  combination  erf 
atheromatous  arteries  and  high  blood-pressure 
is  very  common,  and  the  risks  it  entails  are 
twofold:  (i)  It  may  lead  to  cardiac  failure,  the 
heart  being  unable  to  overcome  the  excessive 
tension,  and  this  is  all  the  more  common  when 
it  is  affected  by  fatty  or  fibroid  degeneration ; 
(2)  a  vessel  may  rupture  in  the  brain,  and  give 
rise  to  sudden  death,  to  hemiplegia,  or,  if  the 
haemorrhage  be  small,  to  local  paralysis,  sensory 
affections,  or  mental  deterioration,  the  result 
depending  on  the  part  of  the  brain  affected. 
Such  small  haemorrhages,  according  to  Ziegler, 
are  very  common.38  Similar  results  may 
ensue  from  blocking  of  the  arteries  by 
atheroma. 

Senile  Decay. — In  the  decade  for  1891  to 
1900  of  persons  above  the  age  of  seventy-five 
years,  no  less  than  34,822  died  from  heart 
disease,  and  39,662  from  diseases  of  the  blood- 
vessels.39 Nor  does  this  even  cover  all  the 
mischief  done  by  diseases  of  the  blood-vessels, 
for  apoplexy,  paralysis,  and  senile  decay  may 
all  be  reckoned  as  secondary  to  disease  of 
the  cerebral  vessels.  In  his  most  instruc- 
tive book,  On  the  Nature  of  Man,  Metch- 


SENILE  DEC  A  Y 


203 


nikoff40  mentions  that  there  are  two  classes 
of  phagocytes  in  the  body :  the  small,  or  micro- 
phags;  and  the  large,  or  macrophags.  The 


PIG.  68. — Cell  from  the  brain  of  a  woman,  aged  100  years,  being  devoured 
by  macrophags.    (Prom  Metchnikoff.) 

function  of  the  microphags  is  to  rid  us  of 
microbes ;  that  of  the  macrophags  is  to  heal 
mechanical  injuries,  such  as  haemorrhages, 


FIG.  69.— Section  of  a  renal  tubule  invaded  by  macrophags,  from  the  body 
of  an  old  man,  aged  90  years  (m= macrophags).    (From  MetchnikofK) 

wounds,  and  so  forth.  In  the  brains  of  old 
persons  and  animals  a  number  of  nerve-cells  are 
surrounded  and  devoured  by  macrophags  (Fig. 


204  DISORDERED  CIRCULATION 

68),  and  Metchnikoff  thinks  himself  justified  in 
asserting  that  senile  decay  is  mainly  due  to 
the  destruction  of  the  higher  elements  of  the 
organism  by  macrophags.  Other  parts  of  the 
body  also  are  not  safe  from  their  attacks,  and 
the  kidneys  may  likewise  suffer  (Fig.  69).  But 
the  function  of  the  macrophags  is  not  to  attack 
healthy  tissues,  it  is  to  remove  those  tissues  the 
vitality  of  which  is  destroyed  or  impaired,  and 
so  long  as  the  brain -cells  are  abundantly 
supplied  with  blood  they  will  probably  be 
allowed  to  remain  uninjured  by  the  attacks 
of  the  macrophags.  I  think,  therefore,  that 
while  senile  decay  may  be  actually  produced  by 
the  macrophags,  we  are  justified  in  believing 
that  it  really  originates  in  an  alteration  of  the 
blood-vessels. 

Embolism  and  Thrombosis.  —  When  the 
blood-vessels  become  obliterated  the  supply  of 
blood  to  the  parts  to  which  they  are  distributed 
may  become  so  insufficient  that  the  tissues  die 
and  gangrene  ensues,  as  in  old  people,  where  the 
arterial  walls  may  become  so  degenerated  and 
their  lumen  so  contracted  that  the  circulation 
is  quite  stopped,  and  senile  gangrene  of  the 
extremities  occurs.  Obliteration  of  an  artery 
may  be  due  to  embolism  or  thrombosis ;  as,  for 
example,  when  a  clot  or  vegetation  becomes 
detached  from  the  heart  and  is  carried  onwards 
by  the  circulation  until  it  is  stopped  in  an  artery 
through  which  it  cannot  pass,  and  which  it 
consequently  plugs.  Sometimes  the  arterial 
wall  undergoes  atheromatous  degeneration,  and 
this  may  either  lead  to  thrombosis  occurring  at 


205 

the  spot  where  the  wall  is  narrowed,  or  the 
atheromatous  matter  may  become  dislodged 
and  produce  embolism  further  on  ; 41  It  is  some- 
times extremely  difficult  to  diagnose  between  a 
case  of  thrombosis  and  haemorrhage ; 42  but  if  the 
tension  is  normal  or  only  slightly  raised,  the 


Fio.  70.— Distribution  of  the  arteries  in  the  brain.    (After  Boss.) 

probabilities  are  in  favour  of  thrombosis,  but  if 
high  in  favour  of  haemorrhage. 

If  the  embolism  or  thrombosis  occur  in  one 
of  the  branches  of  the  Sylvian  artery  the  result 
may  be,  as  mentioned  under  Headache  (p.  1 86), 
aphasia,  partial  blindness,  auditory  disturbance, 
or  monoplegia ;  and  if  the  circulation  to  the 
frontal  lobe  only  is  affected,  there  may  be 
mental  disturbance  without  any  apparent  motor 


206 


DISORDERED  CIRCULATION 


or  sensory  symptoms.  This  will  be  rendered 
clearer  by  a  comparison  of  the  distribution  of 
the  cerebral  arteries  (Fig.  70)  ^  with  that  of  the 
cerebral  functions  (Fig.  7I).44 


Fio.  71.— Cerebral  cortex,  showing  the  distribution  of  function. 
(After  Osier.) 


LITERATURE. 

1  Lauder  Brunton,  "  On  Digitalis,"  etc.,  Collected  Papers 
on  Circulation  and  Respiration,  First  Series,  p.  52 
(London  :  Macmillan  &  Co.). 

2Goltz,  Centralbl.  /.  d.  tned.  Wiss.,  1863,  pp.  17,  497; 
Arch.f.  Path.  Anat.,  1863,  vol.  xxvi.,  p.  10  et  seq. 

3  Goltz,   Centralbl.  f.  d.  tned.   Wiss.,   1863,  p.   593;  and 

Arch.f.  Path.  Anat.,  vol.  xxviii.,  p.  428. 

4  Kratschmer,  Wien.  Sitzungsb.,  1870,  Abt.  2,  vol.  Ixvii., 

p.  24. 

6  Lauder  Brunton,  Brit.  Mea.  Journ.,  4th  December  1875, 
p.  695  ;  and  Practitioner,  1873,  vol.  xi.,  p.  241. 


LITERATURE  OF  CHAPTER  Vlll        207 

6  A.  Mosso,  Die  Diagnostik  des  Pulses  (Leipzig  :  Veit  & 
Co.,  1879),  p.  12  ;  Arch.  Ital.  d.  BioL,  1884,  vol.  v., 
p.  130  et  seq. ;  La  Peur,  p.  69  (Paris  :  Alcan,  1908). 

T  Image,  quoted  by  Lauder  Brunton,  Practitioner,  1873, 
vol.  xi.,  p.  251. 

8  John  Hunter's  Works,  edited  by  Palmer,  1837,  vol.  iii., 

p.  91. 

9  For  discussion  of  low  tension,  vide  Janeway,  Clinical 

Study  of  Blood  Pressure,  p.  152  et  seq.  (New  York 
and  London :  Appleton,  1904). 

10  von  Basch,  Wiener  Med.  Presse,  No.  8,  1900  ;  Allg. 

Physiol.  u.  Path.  d.  Kreisl.  p.  74  (Holder :  Vienna, 
1892). 

11  Lauder  Brunton,  Practitioner,  June    1905,  vol.  Ixxiv., 

P-  735- 

12  du  Bois-Reymond,  Arch,  f,  Anat.  u.  Physiol.,  1860,  p. 

461  et  seq. 

13  Lauder   Brunton,    Trans.    Odontolog.    Soc.  of   Great 

Britain,  1880.  Reprinted  in  Disorders  of  Digestion, 
p.  85  (London  :  Macmillan). 

14  Lauder  Brunton,  Journ.  of  Mental  Science,  April  1902. 

15  Emil  du  Bois-Reymond,  Arch.f.  Anat.  u.  Physiol. ,  etc., 

1860,  p.  468. 

16  Wm.  Russell,  Arterial  Hypertonus,  Sclerosis,  etc.,  p. 

184  (Edin.  and  London  :  Green,  1907) ;  E.  G.  Haw- 
thorne, Clinical  Journ.,  2nd  December  1906. 

17  Goltz,  op.  cit. 

18  Harvey's  Works,  p.  382  (Sydenham  Soc.,  Edin.  and 

London,  1847). 

19  Czermak,  Prager  Vierteljahrsch.,   1868,  vol.  c.,  p.  30 

et  seq.  . 

20  Lauder  Brunton,  "  Cardiac  Pain  and  Angina  Pectoris," 

Practitioner,  1891,  vol.  xlvii.,  p.  241  et  seq. 

21  A.  Morison,  The  Nervous  System,  and  Visceral  Disease, 

p.  757  (Edin.  and  London:  Pentland,  1899);  G.  A. 
Gibson,  Diseases  of  the  Heart  and  Aorta,  pp.  768  and 
787  (Edin.  and  London,  1898) ;  G.  A.  Gibson, 
Nervous  Affections  of  the  Heart,  2nd  ed.,  p.  8  et  seq. 
(Edin.  and  London :  Pentland,  1905) ;  Osier, 
Angina  Pectoris  and  Allied  States  (New  York: 
Appleton,  1897) ;  Mackenzie,  Diseases  of  the  Heart, 
etc.,  p.  42  et  seq.,  292  et  seq.  (London,  1908). 


208  LITERATURE 

22  Allen   Burns,   An  Inquiry  into    the   Symptoms    and 

Causes  of  the  Syncope  Congenosa,  p.   69  (London, 

1799)- 

23  J.   Lindsay   Stevens,   reprint  from  Glasgow  Hospital 

Reports,  1898,  vol.  i.,  p.  236. 

24  Sir    Benjamin    Brodie,   Lectures    on    Pathology    and 

Surgery,  p.  360  (London,  1846). 

25  Lauder  Brunton,  International   Clinics,  1899,  Eighth 

Series,  vol.  iii.,  p.  1 1 1  (London :  T.  Lewin  &  Co.). 

26  Baccelli,  quoted  by  Minella,  Gaz.  d.  Ospedali  e  d.  Clin., 

1902  ;  Abstract  in  Centralb.  f.  inn.  Med.,  1903,  p. 
210.  Huchard,  Maladies  du  Coeur  et  de  P  Aorta, 
3me  ed.,  vol.  ii.,  p.  19,  1899  (Paris  :  O.  Doin). 

27  Pal,  Gefdsskriscn  (Leipzig :  Hirzel,  1905)  ;  and  Wien. 

med.  Wochensch.,  1904,  p.  574. 

28  Lauder   Brunton  and  W.   E.   Williams,   Lancet,   6th 

April  1912. 

29  Lauder  Brunton,  Practitioner,  June  1905. 

30  Raynaud.     For  bibliography,  see  Barlow   in  Clifford 

Allbutt's  System  of  Medicine,  1899,  1st  ed.,  vol.  vi., 
p.  606. 

31  Ziegler,  Pathologische  Anatomie,  8th  ed.,  p.  54  et  seq. 

(Jena :  Fischer,  1895). 

32  Gull  and  Sutton,  Lancet,  1872,  vol.  i.,  p.  794. 

33  Geo.  Johnson,  Lancet,  1877,  vol.  i.,  p.  422. 

34  Rickett,  Journ.  Path,   and  Bacterial.,   1907,  vol.  xii., 

p.  15  et  seq.,  gives  experiments  and  literature. 

35  Durham,  Brit,  and  For.  Med.  Chir.  Rev.,  1861,  vol. 

xxvii ,  pp.  234  and  332  ;  R.  Jones,  Lancet,  1913, 
vol.  ii.,  p.  709. 

38  Friedlander,  Ueber  den  Isopropylalkohol,  Diss.  (Berlin, 
1888). 

37  Lauder  Brunton,  Brit,  Med.  Journ.,  1905,  vol.  ii.,  p.  1 102 

et  seq. 

38  Ziegler,  Lehrb.  d.  Pathol.  Anat.,  8th  ed.,  vol.  ii.,  p.  349 

(Jena:  Fischer,  1895). 

39  Registrar-General  in  Lauder  Brunton  on  "  Longevity,'' 

Lancet,  I7th  November  1906,  vol.  ii.,  p.  1331. 

40  Metchnikoff,   The  Nature  of  Man,  p.  241,  translated 

by  Chalmers  Mitchell  (London  :  Heinemann  ;  New 
York :  Putman,  1903). 

41  For  literature  of  sclerosis  and  atheroma,  vide  Ziegler, 


LITERATURE  OF  CHAPTER  VI II       209 

Lehrb.  d.  Path,  Anat.,  8th  ed.,  vol.  ii.,  p.  58,  and  for 
arteritis,  p.  63  (Jena  :  Fischer,  1895). 

42  Lauder  Brunton,  St  Bartholomew's  Hospital  Reports, 

1891,  vol.  xxvii.,  p.  225  et  seq. 

43  Ross,  Diseases  of  the  Nervous  System,  vol.  ii.,  p.  271, 

(London  :  Churchill,  1883). 

44  Ferrier,  Functions  of  the  Brain  (London  :  Smith,  Elder 

&  Co.) ;  Mills  in  Osier's  Practice  of  Medicine,  ist  ed., 
p.  890  (Edin. :  Pentland,  1892). 


CHAPTER   IX 

ORGANIC  DISEASES  OF  THE   HEART 

Altered  Sounds  of  the  Heart — Alteration  in  the  Second 
Sound — Accentuation — Gallop  Rhythm  —  Alteration 
in  the  First  Sound — Cardiac  Murmurs — Organic — 
Functional  —  Dilatation  from  Cardiac  Strain  — 
Transient  Murmurs — Effects  of  Aortic  Stenosis — 
Effects  of  Aortic  Regurgitation — Failing  Compensa- 
tion— Secondary  Incompetence — Effects  of  Mitral 
Disease  on  Cardiac  Rhythm — Mitral  Regurgitation 
(organic) — Mitral  Obstruction — Cardiac  Dyspnoea — 
— Venous  Engorgement — OZdema — Albuminuria — 
Flatulence — Ascites — Effect  of  Flatulence  on  Heart 
— Other  Forms  of  Cardiac  Disease — Vicious  Circle. 

Alteration  in  the  Second  Sound.  Accentua- 
tion.— When  we  hear  a  door  slammed  loudly 
we  know  that  it  is  closed  quickly  in  consequence 
of  the  application  of  unusual  force ;  and  just  as 
we  would  expect,  when  tension  is  high  in  the 
aorta  the  second  sound  is  louder  than  usual, 
or,  as  it  is  termed,  is  accentuated  ;  and  this 
accentuation  of  the  second  sound  over  the  aorta 
is  one  of  great  clinical  importance,  indicating, 
as  it  usually  does,  high  arterial  tension  or  aortic 
atheroma  or  aneurism.  It  may  be  merely 
temporary  and  due  to  physical  exertion  or 

emotional   excitement.      But  when   it    is   per- 
210 


ALTER  A  TION  IN  SECOND  SO  UND       2 1  r 

manent  it  most  commonly  indicates  arterio- 
sclerosis or  kidney  disease.  When  there  is 
dilatation  of  the  aorta  it  approaches  nearer  to 
the  anterior  wall  of  the  chest,  and  the  sound  is 
louder  than  normal.  When  there  is  calcification 
or  aneurism  of  the  aorta,  the  second  sound  is 
not  merely  louder  but  has  a  peculiar  clanging 
character.  Accentuation  over  the  pulmonary 
cartilage  indicates  increased  pressure  in  that 
artery,  such  as  occurs  in  mitral  stenosis,  or 
regurgitation,  or  in  emphysema. 

When  a  door  is  closed  gently  there  is  little 
sound.  Wrhen  the  pressure  in  the  aortic  and 
pulmonary  arteries  is  low,  the  second  sound  is 
weaker  than  normal. 

Reduplication  of  the  second  sound  is  due  to 
the  aortic  and  pulmonary  valves  not  closing 
simultaneously,  either  because  the  ventricles 
have  not  beat  simultaneously  or  because  greater 
relative  pressure  in  the  pulmonary  artery  or 
aorta  has  caused  prolongation  of  the  systole. 
It  may  occur  in  health  from  the  altered  pressure 
in  the  pulmonary  artery  at  the  end  of  respira- 
tion or  beginning  of  expiration.1 

Gallop  Rhythm. — Normally  the  diastole  is 
much  longer  than  the  interval  between  the  first 
and  second  sounds,  but  if  the  heart  is  beating 
quickly  the  diastole  may  become  shortened  till 
it  equals  the  interval,  and  then  the  sound  is  like 
that  of  a  galloping  horse.2 

It  may  be  best  imitated  by  striking  with 
the  points  of  three  fingers  one  after  another  on 
the  table.  It  is  due  to  the  interpolation  of  a 
third  sound  just  at  the  end  of  diastole.  This  is 


212    ORGANIC  DISEASES  OF  THE  HEART 

probably  caused  by  contraction  of  the  auricles. 
It  is  of  grave  significance,  and  usually  indicates 
great  cardiac  weakness,  occurring  in  infective 
disease  or  chronic  renal  affections. 

Alterations  in  the  First  Sound. — The  causa- 
tion of  the  first  sound  being  more  complex, 
alterations  in  it  occur  from  a  greater  number  of 
causes.  Reduplication  may  occur  from  want  of 
synchronism  in  the  ventricles,  but  may  also 
arise  from  an  auricular  or  ventricular  additional 
sound  2  (cf.  Fig.  15,  p.  43).  As  it  is  to  a  great 
extent  a  muscular  sound,3  we  should  naturally 
expect  that  weakness  of  the  cardiac  muscle, 
such  as  occurs  in  fevers  (p.  1 52),  would  lessen  the 
sound,  and  this  is  exactly  what  happens.  In 
cases  of  typhoid  fever,  when  the  first  sound 
becomes  inaudible,  we  know  that  the  heart  is  so 
weak  as  to  render  the  prognosis  grave.  But  it 
would  appear  that  it  is  not  mere  muscular 
strength  which  causes  the  sound  to  become 
loud,  it  is  rather  rapidity  of  contraction ;  and 
even  a  comparatively  feeble  heart  may  have  a 
loud,  clear  first  sound  if  the  tension  in  the  aorta 
is  low,  or,  in  other  words,  if  the  resistance  it  has 
to  overcome  is  small,  so  that  it  can  contract 
rapidly.  When  the  arterial  tension  is  high,  and 
the  resistance  to  be  overcome  is  consequently 
great,  the  muscular  walls  of  the  ventricle 
contract  comparatively  slowly,  and  even  when 
hypertrophied  far  beyond  their  normal  size 
they  may  give  rise  to  a  sound  weaker  and  duller 
than  normal  Of  course,  the  rapid  contraction 
not  only  gives  rise  to  a  greater  muscular  sound, 
but  it  closes  the  auriculo-ventricular  valves 


ALTERATION  IN  FIRST  SOUND         213 

more  sharply,  and  thus  increases  also  the 
valvular  part  of  the  first  sound.4  And  yet, 
again,  a  heart  contracting  quickly  gives  a  sharp, 
or,  as  it  is  sometimes  called,  a  slapping  impulse 
to  the  chest  wall,  while  the  more  powerful 
hypertrophied  heart,  acting  on  a  greater  resist- 
ance, gives  a  thudding  or  pushing  impulse  not 
likely  to  cause  so  much  resonance,  and  thus  the 
sound  will  again  be  diminished.  The  last  factor 
in  the  production  of  the  first  sound  in  the  heart 
may  also  be  lessened  by  a  thick  layer  of  lung 
between  the  ventricle  and  the  chest  wall,  as  in 
emphysema,  and  the  lung  will  also  tend  to 
deaden  the  sound  by  acting  as  a  non-conductor 
between  the  ventricle  and  the  ear.  Moreover, 
the  impulse  of  the  heart  against  the  chest  wall 
is  also  lessened  and  the  sound  thus  weakened.* 
Cardiac  Murmurs. — When  the  aortic  valves 
are  destroyed,  the  sharp  "  dup "  which  their 
closure  causes  in  health  disappears,  and  is 
replaced  by  a  bruit  or  murmur.6  You  will 
most  easily  understand  this  by  trying  to  say 
"  dup  "  with  your  lips  apart,  and  you  will  then 
find  that  without  thinking  of  it  you  reproduce 
the  sounds  actually  heard  in  aortic  incompetency. 
When  it  is  slight,  the  closure  of  the  valves  is 
still  heard,  but  is  followed  by  a  whiff,  as  when 
you  say  "  duff,"  and  in  aortic  regurgitation  the 
sounds  are  like  "lub-duff."  The  same  happens 
with  the  mitral  valve,  and  when  this  valve  alone 
is  incompetent,  the  sounds  of  the  heart  are  like 

*  The  Committee  of  the  British  Association  found  the 
first  sound  of  the  heart  was  louder  when  the  heart  struck 
against  a  piece  of  board  (Brit.  Ass.  Rep.  1835,  p.  246). 


214    ORGANIC  DISEASES  OF  THE  HEART 

"luff-dup,"  "luff-dup."  When  both  mitral  and 
aortic  valves  are  slightly  incompetent,  the  sounds 
are  like  "  luff-duff,"  "  luff-duff"  ;  and  when  both 
valves  are  very  incompetent,  a  bellows  murmur 
occurs  like  "  oho-oho." 

Cardiac  Murmurs.  Organic. — The  chief  car- 
diac murmurs  are  those  caused  by  obstruction  to 
the  flow  of  blood  onwards  through  the  aortic  or 
mitral  orifices  or  by  regurgitation  of  blood 
backwards  through  them  in  consequence  of 
incompetence  of  the  valves.  In  the  case  of  the 
aorta  slight  roughening  of  its  interior  by 
atheroma  may  give  rise  to  a  systolic  murmur, 
usually  heard  loudest  over  the  second  rib  or 
first  intercostal  space  and  propagated  toward 
the  neck.  This  is  exceedingly  common  in 
elderly  people,  and  may  persist  for  years  without 
the  condition  causing  any  symptoms.  At  the 
same  time  it  indicates  that  the  aorta  is  not 
healthy,  and  if  atheroma  should  invade  the 
coronary  arteries  the  consequences  may  be 
serious.  Such  a  murmur  may,  however,  indicate 
actual  lessening  of  the  aortic  orifice  (stenosis). 
Incompetence  of  the  aortic  valves  is  indicated 
by  a  diastolic  murmur,  usually  heard  loudest 
over  the  aortic  valves,  or  rather  over  the  aortic 
cartilage — propagated  down  the  sternum,  and 
sometimes  heard  even  at  the  apex.  Its 
presence  may  sometimes  be  overlooked,  because 
occasionally  it  is  not  heard  at  the  base  of  the 
heart  at  all,  but  only  at  the  lower  end  of  the 
sternum,  more  especially  to  its  left  side.  Mitral 
obstruction  is  indicated  by  a  pre-systolic  mur- 
mur at  the  apex  which  may  be  imitated  by 


CARDIAC  MURMURS  215 

"hroo-dup."  Regurgitation  is  indicated  by  a 
systolic  murmur  also  at  the  apex. 

Both  aortic  and  mitral  stenosis  are  due  to 
contraction  of  the  orifices  by  inflammatory  pro- 
cesses, and  aortic  and  mitral  regurgitation  are 
usually  due  to  the  valves  being  damaged  by 
similar  processes,  leading  to  deformity  and 
shrinking  of  the  valves,  or  to  the  presence  of 
vegetations  which  prevent  the  proper  apposition 
of  the  cusps  of  the  valve. 

Functional  Murmurs. — But  sometimes  instead 
of  the  valve  being  too  small  for  the  opening, 
the  opening  becomes  too  big  for  the  valve  (Fig. 

24,  P-  75)- 

Both  the  aortic  and  mitral  orifices  receive 
support  from  the  muscular  fibres  which  surround 
them,  and  when  these  contract  imperfectly  the 
orifice  becomes  too  large  for  the  valves,  and 
regurgitation  occurs.  Such  functional  regurgi- 
tation is  common  in  the  tricuspid  and  mitral 
valves,  and  appears  to  occur  but  less  commonly 
in  the  aortic  valves.  It  was  shown  by  Ludwig 
and  Hesse  that  when  the  ventricle  contracts 
normally,  the  muscular  fibres  around  the 
auriculo-ventricular  orifice  lessen  it  to  such 
an  extent  that  even  imperfect  valves  might 
close  it ;  but  when  the  heart  is  dilated,  the 
orifice  becomes  so  large  that  the  valves  will 
not  close  it,  however  healthy  they  may  be  6  (Fig. 

24,  P-  75)- 

Recent  observations  of  Tait  M'Kenzie 7  have 
shown  that  murmurs  which  are  almost  certainly 
functional  are  much  more  common  than  has 
hitherto  been  believed,  and  their  occurrence 


216    ORGANIC  DISEASES  OF  THE  HEART 

has  led  to  many  patients  being  restricted  in 
their  actions  when  they  really  required  regular 
physical  training.  Out  of  1000  students  266 
were  selected  who  presented  no  apparent  defect 
to  an  ordinary  test  After  exertion  by  fifty 
steps  taken  standing,  with  the  knees  high  at 
each  step  so  as  to  excite  the  heart,  it  was  again 
examined,  and  murmurs  were  found  in  74  out 
of  the  266,  that  is,  27-8  per  cent.  In  64  cases 
it  was  present  at  the  pulmonary  artery,  and  in 
35  per  cent  at  that  position  only.  They  were 
much  more  frequent  in  the  recumbent  position. 
The  occurrence  of  cardiac  murmurs  in  nearly 
28  per  cent  of  healthy  men  shows  the  necessity 
of  not  laying  too  great  stress  upon  their  occur- 
rence; but  at  the  same  time  systolic  murmurs 
at  the  apex  occurring  after  exertion  are  apt 
to  indicate  that  the  heart,  although  in  itself 
healthy,  is  not  strong  enough  for  the  amount 
of  exertion  that  has  been  employed,  so  that 
slight  leakage  takes  place  in  the  mitral  valve, 
and  that,  therefore,  a  graduated  course  of  physical 
training  is  necessary  before  any  violent  exercise 
is  undertaken.  In  all  such  cases  I  think  it  is 
advisable  to  ascertain  the  effect  upon  the 
respiration  of  some  exertion,  such  as  walking 
quickly  or  running,  so  as  to  gauge  the  functional 
capacity  of  the  heart.  In  his  paper  Professor 
Tait  M'Kenzie  gives  an  instance  of  the  evil 
results  which  may  occur  from  violent  exercise 
undertaken  without  previous  training.  I  do 
not  know  of  any  good  explanation  of  the 
pulmonary  murmurs  which  occur  in  the  recum- 
bent position,  but  it  seems  just  possible  that  the 


DILATATION— TRANSIENT  MURMURS   217 

pressure  upon  the  pulmonary  artery  or  upon  its 
left  branch  by  the  pericardium,  dragged  down- 
wards and  backwards  by  the  weight  of  the  heart, 
may  cause  a  murmur  to  originate  in  the  same 
way  as  the  pressure  of  the  stethoscope  upon 
the  sub-clavian  artery. 

Dilatation  from  Cardiac  Strain. — Such  dila- 
tation not  only  occurs  as  a  sequence  to  aortic 
regurgitation,  but  it  also  occurs  from  violent 
strain  in  healthy  people,  or  from  cardiac  weakness. 
Indeed  this  happens  not  infrequently  in  cases  of 
anaemia  and  debility,  such  as  occur  after  acute 
disease.  We  then  find  that  a  systolic  murmur, 
indicative  of  mitral  regurgitation,  becomes  very 
evident,  but  as  the  heart  gains  power  the 
murmur  completely  disappears.  One  such 
murmur  I  watched  with  great  interest  in  a 
girl,  who  was  able  to  play  lawn-tennis  without 
any  injury  whatever,  but  every  time  that  she 
went  to  a  dance  the  combination  of  late  hours 
and  emotional  excitement  with  active  exercise 
brought  on  a  marked  systolic  murmur.8 

Transient  Murmurs.  —  Regurgitation  may 
also  occur  from  irregular  action  of  the  musculi 
papillares,  as  I  observed  in  some  experiments 
which  I  made  during  the  year  1865  upon  the 
action  of  digitalis,  and  where  I  heard  a  mitral 
regurgitant  murmur  occur  in  the  heart  of 
a  dog  which  had  been  poisoned  by  digitalis, 
although  post-mortem  examination  showed  the 
heart  to  be  perfectly  healthy.9  Roy  and  Adami 
have  also  made  a  similar  observation  with 
strophanthus.10 

I   have  observed  a  transient  mitral  murmur 

Q 


218    ORGANIC  DISEASES  OF  THE  HEART 

in  a  patient  who  tells  me  he  has  had  it  for 
thirty  years.  When  the  heart  is  quiet  there  is 
often  no  murmur  at  all,  but  when  its  action  is 
excited  a  loud  systolic  murmur  appears  at  the 
apex.  It  may  disappear  again  in  the  course  of 
a  few  minutes.  It  probably  came  on  originally 
from  severe  exertion  taken  for  a  wager,  when, 
I  think,  one  of  the  musculi  papillares  became 
strained,  so  that  afterwards  it  did  not  always 
contract  synchronously  with  the  others,  and 
thus  produced  a  small  chink  between  the  closed 
valves  through  which  regurgitation  took  place. 

Effects  of  Aortic  Stenosis. — Slight  degrees 
of  pure  stenosis  have  little  or  no  effect  upon  the 
circulation,  but  as  the  work  which  the  ventricle 
has  to  do  in  order  to  expel  the  blood  is  increased 
by  the  resistance  in  front,  it  usually  becomes 
hypertrophied.  As  the  amount  of  blood  it  has 
to  send  into  the  aorta  is  not  more  than  usual, 
its  cavity  does  not  increase,  or,  in  other  words, 
does  not  undergo  dilatation. 

Effects  of  Aortic  Regurgitation.  —  When 
there  is  regurgitation,  blood  flows  back  into  the 
ventricle  as  well  as  onwards  towards  the  peri- 
phery. There  is  thus  a  great  difference  between 
systolic  and  diastolic  pressure,  and  the  arteries 
may  be  seen  to  pulsate  largely.  Blood  also 
pours  into  the  ventricle  from  two  orifices,  from 
the  auricle  and  from  the  aorta,  so  that  the 
amount  of  blood  it  is  called  upon  to  hold  is 
greater  than  usual.  Its  cavity  becomes  dilated, 
and  at  the  same  time,  in  order  to  send  this  large 
wave  of  blood  onwards,  its  walls  require  to  be 
stronger  than  usual.  They  become  thicker,  or, 


EFFECTS  OF  AORTIC  DISEASE         219 

in  other  words,  both  dilatation  and  hypertrophy 
occur.  So  long  as  this  compensatory  hyper- 
trophy is  sufficient  to  enable  the  ventricle  to  do 
its  work,  there  may  be  no  symptoms  at  all,  and 
I  have  seen  patients  suffering  from  aortic 
regurgitation  who  were  nevertheless  engaged 
in  arduous  physical  labour,  carrying  heavy  hods 
of  bricks  up  ladders  many  times  a  day,  without 
knowing  that  there  was  anything  the  matter 
with  them.  Not  infrequently  one  may  notice 
that  the  face  has  a  peculiarly  pale  waxy  look 
and  the  arteries  show  a  peculiar  irritability 
(p.  88),  so  that  when  the  finger-nail  is  sharply 
drawn  across  the  forehead  a  red  mark  appears 
which  shows  three  kinds  of  pulsation.11 

Failing  Compensation.  —  But  the  enlarged 
heart  requires  an  extra  supply  of  blood,  and  the 
coronary  arteries  may  by  and  by  become  insuffi- 
cient to  supply  this,  and  then  cardiac  failure 
commences  to  set  in.  When  this  is  the  case, 
symptoms  of  defective  supply  of  blood  to  the 
brain  occur,  such  as  indecision,  giddiness, 
tendency  to  faint,  or  actual  fainting ;  and 
symptoms  referable  to  the  heart  also,  such  as 
palpitation,  cardiac  uneasiness,  or  anginal  pain. 

Secondary  Incompetence  (Functional).— So 
long  as  the  mitral  valves  remain  competent,  the 
symptoms  remain  limited  to  those  parts  of  the 
body  supplied  by  the  aorta.  But  when  the 
heart  dilates  so  far  that  the  mitral  valves  no 
longer  close  the  auriculo-ventricular  orifice,  so 
that  the  blood  pours  back  into  the  left  auricle 
and  pulmonary  veins,  symptoms  of  pulmonary 
engorgement  develop  (p.  222). 


220    ORGANIC  DISEASES  OF  THE  HEART 

Effect  of  Mitral  Disease  on  the  Cardiac 
Rhythm. — When  the  mitral  valves  become 
incompetent,  the  reflux  of  blood  at  each  beat 
of  a  powerful  ventricle  tends  to  distend  the 
auricle  and  the  pulmonary  veins  from  which  the 
normal  stimulus  to  ventricular  contraction 
ought  to  start.  In  consequence  of  this  the 
cardiac  rhythm  is  apt  to  be  disturbed,  and  an 
irregular  pulse  will  result.  For  this  reason 
irregularity  of  the  pulse  is  more  frequent  in 
mitral  than  in  any  other  form  of  cardiac  disease, 


FIG.  72. — Irregular  pulse  from  a  case  of  mitral  regurgitation  and  probably 
adherent  pericardium. 

and  it  is  even  more  marked  in  mitral  obstruc- 
tion than  in  mitral  regurgitation,  probably 
because  in  the  former  disease  there  is  constant 
instead  of  intermittent  stimulation  of  the  auricle 
and  great  veins  by  the  pressure  of  blood  in 
them. 

Mitral  Regurgitation  (Organic). — Incompe- 
tence of  the  mitral  valves  occurs  from  distortion 
of  the  valves  by  inflammation,  or  by  vegetations 
on  their  surfaces  which  prevent  them  from  clos- 
ing, even  more  frequently  than  from  dilatation 
of  the  auriculo-ventricular  orifice.  The  result, 
however,  is  the  same.  Whenever  the  valves 
are  incompetent  the  ventricle  drives  the  blood 


EFFECTS  OF  MITRAL  DISEASE        221 

at  each  systole  back  into  the  auricle  and 
pulmonary  veins,  as  well  as  forward  into  the 
aorta,  and  during  systole  the  pressure  in  the 
auricle  and  in  the  pulmonary  veins  must  be 
nearly,  if  not  quite  so  high,  as  that  in  the  aorta. 
In  consequence  of  this,  the  auricle  becomes 
hypertrophied.  As  there  are  no  valves  in  the 
pulmonary  veins,  it  seems  extraordinary  that 
the  pulmonary  vessels  do  not  suffer  more  than 
they  do,  and  it  appears  to  me  not  improbable 
that  the  contractile  power  of  the  pulmonary 
veins,  which  Sir  Joseph  Fayrer  and  I  redis- 
covered, may  take  the  strain  off  the  capillaries 
in  the  lungs,  and  thus  prevent,  to  some  extent, 
the  tremendous  congestion  that  might  otherwise 
take  place. 

Mitral  Obstruction. — When  the  mitral  valves 
are  much  inflamed,  they  not  infrequently  become 
adherent  to  one  another,  and  the  mitral  orifice 
is  thus  so  much  narrowed  that  sometimes  it  will 
hardly  admit  the  point  of  the  finger.  Great 
hypertrophy  of  the  auricle  then  occurs,  while 
the  ventricle  may  be  smaller  than  normal.  In 
such  a  condition  the  pressure  within  the 
pulmonary  veins  and  the  auricle  tends  to  be 
more  or  less  constantly  high,  while  that  in  the 
ventricle  becomes  low  after  the  systole  is  over. 

I  mentioned  before,  when  speaking  of  the 
physiology  of  the  heart,  that  dilatation  of  the 
apex  of  the  frog's  heart  by  pressure  from  within 
would  act  as  a  stimulus  to  this  portion  of  the 
ventricle,  and  cause  it  to  beat  rhythmically 
when  it  would  otherwise  remain  perfectly  still 
(p.  29).  The  application  of  this  constant 


222     ORGANIC  DISEASES  OF  THE  HEART 

pressure  to  the  left  auricle,  while  it  is  absent 
from  the  left  ventricle,  naturally  tends  to  disturb 
the  rhythm,  and  consequently  causes  irregularity 
of  the  pulse.  Moreover,  Schiff  found V1  that 
the  rhythmical  contractions  in  veins  observed 
by  Wharton  Jones13  depend  on  the  pressure 
inside  the  veins,  being  well  marked  when  the 
pressure  is  high,  and  absent  when  the  pressure 
is  low.  If  this  holds  good  for  the  venae  cavae 
and  pulmonary  veins,  which  also  possess  the 
power  of  rhythmical  contraction,14  the  pressure 
of  the  blood  in  the  pulmonary  veins  in  mitral 
obstruction  may  excite  stimuli  in  them,  whose 
rhythm  may  interfere  with  others  originating 
in  the  auricles  or  ventricles.  It  is  probably  in 
consequence  of  such  abnormal  stimuli  excited 
by  the  pressure  in  the  auricles  and  pulmonary 
veins,  and  possibly  in  the  venae  cavae,  that  irregu- 
larity of  the  heart's  action  is  more  frequent  in 
mitral  constriction  than  in  any  other  form  of 
cardiac  disease. 

Cardiac  Dyspnoea.  —  Involuntary  muscular 
fibre  seems  to  have  less  power  of  withstanding 
strain  when  it  is  constant  than  when  it  is  inter- 
mittent, and  it  is  in  mitral  obstruction  that  we 
most  frequently  find  the  pulmonary  capillaries 
giving  way  before  the  strain  and  haemoptysis 
occurring. 

Backward  pressure  in  the  pulmonary  circula- 
tion, of  course,  retards  circulation  through  the 
lungs ;  less  blood  can  pass  through  in  a  given 
time,  and  consequently,  both  in  mitral  regurgita- 
tion  and  in  mitral  obstruction,  shortness  of 
breath  is  a  prominent  symptom.  A  patient  may 


VENOUS  ENGORGEMENT  223 

be  perfectly  comfortable  while  at  rest,  but  there 
is  no  reserve  power,  and  exertion  at  once  brings 
on  quickened  breathing  and  distress,  which  may 
sometimes  be  very  severe.  In  consequence  of 
this  obstruction  to  the  pulmonary  circulation, 
the  right  ventricle  has  more  resistance  to  over- 
come ;  it  is  obliged  to  contract  with  more  force, 
and  on  account  of  the  increased  work  tends  to 
become  hypertrophied.  As  a  rule,  its  working 
power  becomes  more  and  more  taxed  until  the 
maximum  is  reached,  and  then  it  begins  to 
dilate,  so  that  the  tricuspid  valves  become  in- 
competent and  the  blood  pours  back  into  the 
auricle  and  the  venae  cavae  (cf.  Fig.  24,  p.  75). 

Venous  Engorgement. — Dilatation  and  hy- 
pertrophy of  the  auricle  occur  in  the  same  way 
as  on  the  left  side,  but  there  being  no  valves  in 
the  venae  cavae,  the  whole  venous  system  is 
likely  to  become  engorged.  The  first  indication 
of  venous  engorgement  is  shown  in  those  parts  of 
the  body  where  the  venous  pressure  is  greatest, 
namely,  in  the  feet  and  ankles,  because  in  these 
places  there  is  not  only  the  backward  pressure 
which  exists  in  the  vena  cava  itself,  but  the 
weight  of  the  column  of  blood  between  the  feet 
and  the  heart.  It  is  this  extra  weight  that 
determines  the  yielding  of  the  venous  capillaries 
and  the  exudation  of  fluid.  This  is  shown  by 
the  fact  that  when  the  weight  of  blood  is  taken 
off  the  feet  by  keeping  them  raised  upon  a  high 
stool  or  chair  during  the  day,  or  by  putting  the 
patient  to  bed,  the  oedema,  as  a  rule,  disappears. 
Next  the  liver  and  portal  system  suffer.  The 
liver  becomes  congested  and  enlarged,  and 


224     ORGANIC  DISEASES  OF  THE  HEART 

flatulence,  both  in  the  stomach  and  intestine, 
becomes  a  troublesome  symptom.  As  the  con- 
gestion increases  the  liver  may  be  felt  hard, 
smooth,  and  large,  reaching  down  sometimes  to 
the  iliac  crest,  pulsation  may  occur  in  it,  and 
water  exudes  into  the  abdominal  cavity,  pro- 
ducing ascites.  The  kidneys  also  become 
congested.  The  increased  venous  pressure 
lessens  the  circulation  through  the  glomeruli, 
the  urine  becomes  scanty  and  loaded  with 
lithates,  and  then  album inuria  appears. 

CEdema. — The  accumulation  of  serous  fluid 
in  the  intercellular  spaces  of  the  tissues,  which 
constitutes  oedema,  is  due  in  great  measure  to 
venous  congestion,  but  weakness  of  the  vaso- 
motor  nerves  also  plays  a  part  in  its  occurrence. 
By  ligaturing  the  vena  cava  in  a  dog,  Ranvier 
caused  venous  congestion  in  both  extremities, 
but  oedema  only  came  on  in  the  leg  of  which 
the  sciatic  nerve  had  been  cut.  He  proved  that 
its  occurrence  was  due  to  paralysis  of  the  vaso- 
motor,  and  not  of  the  motor  fibres,  by  cutting 
the  motor  roots  of  the  nerve  on  one  side  and 
the  sympathetic  (vaso-motor)  roots  on  the  other. 
Then  oedema  came  on  the  side  where  the  sym- 
pathetic roots  were  cut,  although  the  limb 
retained  its  motor  power,  and  remained  absent 
from  the  other  limb,  although  it  was  paralysed.15 

Albuminuria.  —  The  albuminuria  of  venous 
engorgement  is  really  a  kind  of  oedema  in  the 
kidney,  the  serous  fluid  flowing  away  through 
the  ureter  just  as  it  does  from  cedematous  legs 
when  they  are  punctured.  It  is  quite  a  different 
thing  from  albuminuria  due  to  organic  disease 


ALBUMINURIA—FLA TULENCE—ASCITES  225 

of  the  kidney,  and  so  does  not,  like  it,  form  a 
contra-indication  to  the  use  of  opium.  Of 
course  this  form  of  albuminuria  may  occur  in 
persons  who  are  already  suffering  from  kidney 
disease,  a  condition  which  might  necessitate 
caution. 

Flatulence. — The  venous  stasis  in  the  stomach 
and  intestines  prevents  the  absorption  of  gas 
from  them,  even  if  it  does  not  increase  its 
formation,  and  greatly  adds  to  the  patient's 
discomfort. 

Ascites.  —  The  usual  consequences  of  ab- 
dominal venous  congestion  are  first  "wind" 
and  then  "  water,"  first  intestinal  flatulence,  and 
then  serous  fluid  accumulating  in  the  peritoneal 
cavity,  which,  by  pressing  the  diaphragm  up- 
wards, increases  the  difficulty  of  breathing, 
and  by  pressing  on  the  ureters  obstructs  the 
flow  of  urine  through  them  and  lessens  its 
already  too  scanty  amount. 

Effect  of  Flatulence  on  the  Heart. — Flatu- 
lent distension  without  ascites  is  very  common 
indeed,  and  so  is  flatulent  distension  with 
ascites ;  but  ascites  without  flatulence  is  rare. 
The  relief  which  patients  with  cardiac  disturb- 
ance feel  when  flatulence  escapes  from  the 
stomach  is  very  marked,  not  only  in  cases  of 
valvular  disease,  but  in  cardiac  weakness  and  in 
angina  pectoris.  The  modus  operandi  of  gastric 
distension  in  disturbing  the  action  of  the  heart 
is  probably  twofold.  It  may  depress  it  reflexly 
(Fig.  1 06, p.  358)  or  mechanically.  The  heart  rests 
upon  the  upper  surface  of  the  stomach,  with  only 
the  thin  diaphragm  between,  and  if  the  stomach 


226     ORGANIC  DISEASES  OF  THE  HEART 

is  distended  it  raises  the  heart  up;16  and  by 
thus  altering  its  position  it  tends  to  tilt  it  up  and 
bring  the  apex  close  to  the  chest  wall.  It  may 
thus  cause  palpitation  (p.  175).  Not  only  so,  but 
it  seems  also,  by  altering  the  axis,  to  interfere  with 
the  heart's  action,  and  may  produce  distress  or 


Fio,  tz. — Diagram  of  the  effect  of  flatulent  distension  of  the  stomach  on 
the  heart.  The  dark  line  shows  the  normal  position  of  the  viscera. 
The  dotted  line  shows  their  position  when  the  stomach  is  distended. 

even  death.  Several  years  ago  I  saw  a  notice 
of  a  man  who  died  suddenly,  and  on  post- 
mortem examination  he  was  found  to  be 
perfectly  healthy,  but  the  stomach  was  dis- 
tended with  a  mixture  of  potatoes  and  milk. 
This  had  begun  to  ferment,  and  the  pulpy  mass 
being  of  an  adhesive  character,  the  gas  was 


EFFECT  OF  FLATULENCE  ON  HEART   227 

unable  to  escape  from  it,  and  caused  such 
distension  of  the  stomach  that  death  occurred. 
The  mechanism  here  is,  of  course,  uncertain, 
because  the  acute  distension  may  have  produced 
reflex  stoppage  of  the  heart,  but  in  all  proba- 
bility the  mechanical  effect  had  a  great  deal  to 
do  with  it.  A  year  or  two  ago  I  saw  another 
similar  case  recorded,  where  death  was  put  down 
to  tea.  In  this  instance  the  bread  and  tea  had 
apparently  formed  a  mass  like  the  potatoes  and 
milk  in  the  former  case,  and  had  a  similar  effect. 
In  former  times  one  mode  of  punishing  by 
death  was  to  make  the  condemned  person  drink 
bull's  blood  warm  from  the  vessels  of  the 
slaughtered  animal.17  Blood  in  itself  is  not  a 
poison,  but  as  the  criminal  had  to  drink  it  in 
large  quantities  it  coagulated  in  the  stomach 
and  formed  a  solid  clot  which,  either  reflexly  or 
mechanically,  caused  death.18  Under  ordinary 
circumstances  distension  of  the  stomach,  unless 
extreme,  will  not  displace  the  heart  and  encroach 
upon  the  lungs,  because  the  abdominal  walls  will 
yield,  and  the  intestines,  partially  distended  as 
they  usually  are  with  gas,  will  become  com- 
pressed before  any  displacement  of  the  heart 
can  occur.  But  if  the  abdomen  is  distended 
by  fluid,  or  if  it  is  constricted  by  a  belt  or  by 
corsets,  flatulent  pressure,  being  prevented  from 
exerting  its  force  in  a  downward  or  outward 
direction,  will  push  the  heart  up,  and  death 
may  result.  For  this  reason,  as  was  shown  by 
the  Hyderabad  Chloroform  Commission,  tight- 
lacing  is  dangerous  during  the  administration  of 
anaesthetics.19  It  tends  to  increase  the  liability 


228    ORGANIC  DISEASES  OF  THE  HEART 

to  palpitation,  and  explains  the  efficacy  of  the 
common  practice  of  at  once  loosening  the 
corsets  in  cases  of  fainting. 

Other  forms  of  Cardiac  Disease. — It  is  obvious 
that  all  the  conditions  I  have  just  described 
may  result  as  consequences  of  mitral  disease 
either  primary  or  secondary  to  aortic  regurgita- 
tion,  but  the  number  of  these  conditions  will  be 
greater  or  less  in  other  forms  of  cardiac  disease, 
according  to  the  point  in  the  circulation  where 
the  lesion  occurs.  Thus,  we  may  have  all  the 
symptoms  of  venous  engorgement  from  weak- 
ness of  the  right  ventricle  and  inability  to  drive 
the  blood  through  the  lungs.  This  weakness 
may  be  absolute,  due  to  fatty  degeneration  of 
the  cardiac  muscle,  consequent  upon  atheroma 
of  the  right  pulmonary  artery ;  or  it  may  be 
relative,  due  to  greater  resistance  to  the  circula- 
tion in  the  lungs  themselves,  as,  for  example,  in 
chronic  bronchitis  and  emphysema.  A  very 
instructive  experiment  in  regard  to  this  is  that 
known  by  the  name  of  Valsalva.  If  one  expires 
very  forcibly  against  resistance,  as  by  closing 
both  mouth  and  nostrils,  the  pulse  stops  entirely 
when  the  pressure  reaches  a  certain  point.  It 
is  probably  from  this  cause  that  death  some- 
times occurs  from  straining  at  stool. 

In  efforts  of  coughing,  expiration  is,  of  course, 
made  against  raised  pressure  caused  by  the 
closure  of  the  false  vocal  cords,  which  yield  in 
an  explosive  manner  after  the  pressure  has 
become  raised  to  a  certain  extent,  and  mucus  is 
carried  out  by  the  forcible  stream  of  air  issuing 
from  the  lungs.  In  violent  coughing,  the  effect 


OTHER  FORMS  OF  CARDIAC  DISEASE  229 

of  raised  pressure  in  the  pulmonary  alveoli 
upon  the  pulmonary  circulation  becomes  very 
evident.  The  face  becomes  congested,  and  if 
the  coughing  be  long  continued  becomes  more 
or  less  livid,  and  the  jugular  veins  stand  out 
largely  upon  the  neck.  In  people  who  are 
otherwise  healthy,  the  ventricle  recovers  itself 
when  the  coughing  ceases,  but  prolonged  strain, 
as  in  chronic  bronchitis  or  spasmodic  asthma, 
tends  to  cause  permanent  dilatation  of  the  right 
side  of  the  heart,  with  all  its  attendant  evils. 

Vicious  Circle. — As  in  many  other  things, 
the  conditions  in  cardiac  disease  form  a  vicious 
circle.  The  disordered  circulation  disturbs  the 
functions  of  other  organs,  and  these  in  turn 
make  the  circulation  worse.  The  condition, 
indeed,  reminds  one  of  the  old  lines  in  regard 
to  sorrow  : — 

"  Sorrow's  weight  doth  heavier  grow 
Through  debt 
That  bankrupt  sleep  doth  sorrow  owe." 

The  disordered  circulation  interferes  with  the 
functions  of  the  lungs,  liver,  stomach,  intestines 
and  kidneys.  On  account  of  the  difficulty  of 
breathing,  exercise  becomes  impossible,  and 
thus  all  the  accessory  aids  to  circulation  given 
by  the  muscles  and  fasciae  during  movement  are 
done  away  with.  Appetite  becomes  lessened  and 
flatulence  increases ;  the  elimination  of  waste 
products  by  the  kidneys  is  interfered  with,  and 
distension  of  the  abdomen,  either  by  flatulence 
alone  or  by  flatulence  with  ascites,  presses  the 
diaphragm  up,  encroaches  upon  the  breathing 


230    ORGANIC  DISEASES  OF  THE  HEART 

space  in  the  lungs,  and  tilts  the  heart  up,  thus 
still  further  increasing  its  difficulties.  In  such 
cases  it  is  evident  that  the  patient  is  bound  to 
die,  and  to  die  a  somewhat  painful  death,  unless 
medical  art  can  afford  him  assistance.  It  is 
very  fortunate,  however,  that  in  such  cases 
medical  art  can  do  so  much. 


LITERATURE. 

I  von  Dusch,  quoted  by  Landois  and  Stirling,  Physiology, 

4th  ed.,  vol.  i.,  p.  83  (London  :  Griffin,  1891). 

-  For  discussion  of  this,  see  Gerhardt,  Arch.f.  exp.  Path, 

u.  Pharm.,  1894,  vol.  xxxiv.,  p.  361  ;  and  Sahh,  Lehrb. 
.  d.  klin.  Untersuchungs  Methoden,  Leipzig  and  Vienna, 
2nd  ed.,  1899,  p.  276  ;  also,  A.  James,  Scot.  Med.  and 
Surg.  Journ.,  June  1899,  vol.  iv.,  p.  533. 
3  Ludwig    and    Dogiel,   Sitzungsb.   d.  sacks.   Gesellsch. 
d.  Wiss.  math.-phys.  Kl.,  1868,  p.  96  ;  and  Ludwig's 
Arbeiten  for  1868,  p.  75. 

*  Guttmann,  Virch.  Arch.,  1869,  vol.  xlvi.,  p.  105  et  seq.; 

Ottomar  Bayer,  Arch.  d.  Heilk.,  1870,  vol.  xl,  p.  157. 
6  Sixth  Report  of  the  British  Association,  1836,  p.  264. 

6  Ludwig  and  Hesse,  Arch.  f.  Anat.  u.  Physiol.  Anat. 

Abt.,  1880,  p.  344  ;   Roy  and  Adami,  Practitioner, 
1890,  vol.  xliv.,  p.  348. 

7  Tait- Mackenzie,  Amer.  Journ.  of  Med.  Sciences,  1913, 

vol.  cxliv.,  p.  69 ;   Schlieps,  Jahrb.  f.  Kinderheilk., 
September  1912,  p.  247. 

8  Lauder    Brunton,    "  Rest    and    Massage    in    Cardiac 

Affections,"  Practitioner,  1893,  vol.  li.,  p.  190  et  seq. 

9  Lauder  Brunton,  Collected  Papers  on  Circulation  and 

Respiration,   First    Series,    1907,   p.    114  (London: 
Macmillan). 

10  Roy  and  Adami,  Practitioner,  1890,  vol.  xliv.,  p.  348. 

II  Lauder  Brunton,  Journ.  of  Physiol.,  1884,  vol.  5,  p.  14. 
12  Schiff,   Roser,    and    Wunderlichs,   Arch.  f.  physiol. 

Heilk.,  1855,  vol.  xiii.,  p.  523. 


LITERATURE  OF  CHAPTER  IX         231 

13  Wharton  Jones,  Phil.  Trans.,  1852,  p.  131. 

14  Brunton  and  Fayrer,  Proc.  Roy.  Soc.,  1874,  vol.  xxii., 

p.  125  ;  and  Proc.  Roy.  Soc.t  1876,  vol.  xxv.,  p.  72. 
16  Ranvier,  Compt.  rend.,  1869,  tome  Ixix.,  p.  1326. 

16  Barclay,   Brit.  Med.  Journ.,  28th    September    1912, 

p.  778. 

17  Marx,  Gtftlehre,  vol.  i.,  p.  268 ;   Herodotus,  lib.  Hi., 

Thalia,  c.  15. 

18  This  explanation   was  known    to   Pliny,   Hist.  Nat., 

lib.  xi.,  c.  38,  section  90,  quoted  by  Marx,  Giftlehre. 

19  Med.  Press  and  Circ.,  1890,  vol.   i.,  p.  235  ;  Lancet^ 

1890,  vol.  i.,  p.  662. 


CHAPTER   X 

,  METHODS  OF  TREATMENT   IN   CARDIAC 
DISEASE 

Uses  of  Treatment — Rest — Rules  regarding  Rest  for 
Patients — Position — Commodes — Massage — Results 
of  the  combined  Use  of  Rest  and  Massage — Gradu- 
ated Exercises  —  Oxygen  —  Nauheim  Treatment — 
Baths  and  Exercises — Oertel's  Treatment — Diet — 
Sports  —  Milk  Diet  —  Chloride-free  Food  —  Sugar 
Treatment  for  Failing  Heart — Means  of  Modifying 
the  Circulation  Locally — Heat  and  Cold — Fomenta- 
tions— Poultices — Local  Bleeding — General  Bleed- 
ing— Method — Tapping  for  (Edema — Tapping  for 
Ascites — Plasters  over  the  Heart — Blisters. 

Uses  of  Treatment.  Rest. — There  is  perhaps 
no  kind  of  disease  in  which  the  results  of  treat- 
ment are  so  striking  and  so  encouraging  as  in 
cardiac  disease.  If  we  can  break  the  vicious 
circle  at  one  point,  we  allow  recovery  to  com- 
mence ;  and  one  of  the  most  important  agents — 
I  think  I  ought  to  say  the  most  important  agent 
— in  the  physician's  power  is  absolute  rest}-  It 
is  very  hard  indeed  to  make  patients  understand 
what  one  means  by  absolute  rest.  They  are 
inclined  sometimes  to  take  the  expression  as 
meaning  that  they  shall  stay  in  the  house,  but 
that  they  may  go  up  and  down  stairs  as  often 

282 


TREATMENT  BY  REST  233 

and  as  quickly  as  they  please.  Now,  few  people 
have  any  idea  of  the  amount  of  work  involved 
in  going  upstairs.  The  weight  of  the  body  is  so 
evenly  distributed  upon  the  muscles  of  the  legs 
that  we  hardly  feel  the  exertion  in  health,  but  if 
we  suppose  that  we  had  fixed  upon  the  ban- 
nisters of  the  stairs  on  the  bedroom  floor  a 
strong  pulley  provided  with  rope  and  basket, 
and  that  the  patient,  weighing,  let  us  say,  150 
Ibs.,  is  put  into  the  basket  on  the  ground  floor, 
and  that  we  had  to  pull  him  up  by  means  of  the 
rope,  we  will  then  understand  the  number  of 
foot-pounds  involved  in  the  amount  of  exertion 
required  to  bring  him  from  the  dining-room 
floor  to  his  bedroom.  The  weight  is  the  same 
and  the  height  is  the  same  when  the  patient  is 
drawn  up  in  a  basket  and  when  he  walks  up 
himself.  By  putting  the  position  before  a 
patient  in  this  way  I  have  sometimes  succeeded 
in  convincing  him  that  the  work  involved  in 
walking  upstairs  was  really  great,  and  more 
than  his  enfeebled  heart  could  stand.  But  it  is 
not  merely  in  walking  upstairs  that  the  heart 
has  extra  work  to  do.  Even  in  getting  into 
bed  work  requires  to  be  done,  and,  unfortun- 
ately, as  in  the  case  of  a  patient  whom  I  saw 
immediately  after  giving  my  third  lecture,  the 
exertion  of  getting  into  bed  may  prove  fatal. 

When  patients  are  well  enough  to  walk  gently 
upstairs,  but  still  require  care,  they  may  be  in- 
structed to  walk  upstairs  backwards  or  rather 
sidewise,  as  this  renders  hurry  almost  impossible. 

Rule  regarding  Rest  for  Patients.  —  The 
advice  I  give  to  patients  is,  that  they  shall  not 

R 


234     TREATMENT  IN  CARDIAC  DISEASE 

take  one  beat  out  of  their  heart  that  can  possibly  be 
avoided  ;  that  they  shall  not  do  one  thing  for  them- 
selves which  anybody  else  can  do  for  them.  No- 
body else  can  breathe  for  them,  nobody  else  can 
swallow  for  them,  nobody  can  evacuate  for  them  ; 
but  with  these  exceptions  everything  else  should 
be  done  for  them.  When  they  wish  to  sit  up  in 
bed,  they  should  be  raised  up  by  others  ;  when 
they  wish  to  turn,  others  should  move  them ; 
when  they  wish  to  evacuate,  a  bed-pan  should 
be  placed  under  them. 

Position. — But  here  we  are  met  at  once  with 
the  great  objection  that  in  these  severe  cases 
the  patient  cannot  lie  down  on  account  of 
difficulty  in  breathing.  The  cause  of  this 
difficulty  of  breathing  while  in  the  recumbent 
position  is  probably  of  twofold  origin.  In  the 
first  place,  when  the  patient  is  supine,  the 
contraction  of  the  diaphragm  at  each  inspira- 
tion has  to  raise  the  abdominal  viscera,  while 
in  the  upright  position  it  has  only  to  push  them 
horizontally  forward.2  Another  cause  is  probably 
the  extra  tension  in  the  right  side  of  the  heart, 
which  occurs  when  the  heart  is  brought  down 
to  a  level  with  the  splanchnic  area ;  and  the 
comparative  ease  which  occurs  in  the  upright 
position  is  due  to  the  blood  remaining  in  the 
abdomen  and  limbs,  so  that  the  tension  in  the 
right  side  of  the  heart  becomes  less.  In  some 
cases  the  facts  that  when  the  legs  are  raised 
the  venous  tension  in  the  cava  becomes  some- 
what greater  than  when  they  are  dependent, 
and  also  that  when  the  thighs  are  swollen  there 
is  a  little  extra  pressure  exerted  on  the  abdomen, 


235 


make  it  necessary  that  the  patient  should  be 
allowed  to  sit  and  not  be  confined  to  bed.  But 
if  he  is  sitting,  he  should  be  kept  always  in  the 
same  position  ;  he  should  not  get  up  at  all,  and 


FIG.  74. — Diagram  to  show  the  lifting  of  the  abdominal  contents  during 
inspiration  in  the  supine  position. 


FIG.  75. — Diagram  to  show  the  horizontal  motion  of  the  abdominal 
contents  in  the  upright  position. 

he  should  have  not  an  ordinary  chair  but  a  night- 
stool,  so  that  the  evacuations  may  be  removed 
without  disturbing  him.  Various  beds  have 
been  devised  upon  which  patients  can  lie 


236     TREATMENT  IN  CARDIAC  DISEASE 

comfortably  and  have  their  bodies  and  limbs 
placed  at  any  angle  that  is  desired  without  any 
exertion  whatever  on  the  part  of  the  patient ; 
but  although  these  are  theoretically  very  useful,  , 
they  are  not  so  much  used  in  practice  as  I 
think  they  might  be. 

Commodes. — One  great  difficulty  in  treating 
many  cases  of  cardiac  diseases  is  that  some  of 
them  really  cannot  empty  their  bowels  in  the 
recumbent  position.  Many  say  at  first  that 
they  cannot  do  it,  but  with  patience  and 
persuasion  they  learn  to  do  so.  In  other  cases 
these  are  in  vain  and  the  patients  must  get  up. 
They  must  be  assisted  as  much  as  possible  and 
lifted  back  into  bed,  for,  as  I  have  said,  the 
exertion  of  climbing  back  may  prove  instantly 
fatal.  It  is  best  to  have  a  commode  raised  to  the 
height  of  the  bed  on  some  kind  of  platform  so 
that  the  patient  can  simply  be  shoved  on  and 
off  it  without  altering  the  level  of  his  pelvis,  the 
only  change  being  in  the  relative  position  of 
the  trunk  and  limbs.  Commodes  are  now 
made  which  effect  this  purpose.3 

Use  of  Massage. — It  is  evident  that  when 
the  patient  is  resting  completely,  either  in  bed 
or  in  a  chair,  all  the  accessory  means  of  circula- 
tion in  the  limbs  of  which  I  have  already  spoken 
are  absent,  and  not  infrequently  one  finds  that 
the  feeble  circulation  in  the  muscles,  and  the 
consequent  accumulation  of  waste  products,  give 
rise  to  feelings  of  heaviness  in  the  limbs,  dis- 
comfort, and  restlessness  which  are  very  trying 
to  the  patient.  In  health,  the  arteries  which 
run  in  the  same  sheath  as  the  nerves  exercise  a 


MASSAGE  237 

kind  of  massage  upon  them  by  their  alternate 
contraction  and  expansion,  in  the  same  way  as 
on  the  veins ;  but  when  the  pulse  is  feeble  the 
nerves  suffer  in  consequence.*  The  indication 
for  treatment  here  is  to  replace  the  natural 
accessories  to  circulation  as  far  as  possible  by 
artificial  ones,  and  this  we  are  able  to  do  to  a 
certain  extent  by  skilful  massage.  Massage  is 
one  of  the  most  powerful  agents  in  the  treatment 
of  such  cases.4  It  is  a  therapeutic  agent  of  very 
great  power  and  value ;  but,  like  opium,  which 
from  its  utility  has  been  termed  God's  greatest 
gift  to  man,  it  is  liable  to  abuse,  and  on  account 
of  its  abuse  it  is  often  looked  upon  askance. 
But  just  as  we  cannot  afford  to  throw  opium 
aside  as  a  medicine  because  it  is  liable  to  abuse, 
so  we  must  employ  massage  if  we  are  to  do  the 
best  for  our  patients,  and  at  the  same  time  we 
must  guard  as  far  as  possible  against  any  chance 
of  abuse.  By  slow,  firm,  upward  strokes  along 
the  legs  and  arms,  the  venous  blood  is  forced  on- 
wards towards  the  heart,  and  the  fluid  which  has 
accumulated  in  the  intercellular  tissue  is  drawn 
on  into  the  lymphatics.  Thus  the  resistance 
which  the  flow  of  blood  through  the  arterioles 
and  capillaries  has  to  overcome  is  lessened,  and 
the  work  of  the  heart  lightened.  The  weariness, 
the  weight,  and  the  discomfort  of  the  limbs  are 
removed,  and  the  restlessness  and  irritability  of 
the  patient  lessened.  Over-massage,  however, 
acts  like  over-exercise,  and  does  harm. 

Results  of  Combined  Rest  and  Massage. — 
The  combined  effects  of  rest  and  massage  are 

.  156. 


238     TREATMENT  IN  CARDIAC  DISEASE 

that  the  heart  beats  more  slowly,  has  a  longer 
period  of  repose  between  .each  beat,  and  has 
less  work  to  do  at  each  systole.  Thus  the 
process  of  repair  is  allowed  to  begin. 

The  lessened  resistance  allows  each  cavity  to 
contract  more  perfectly,  the  longer  pause  allows 
each  cavity  to  become  more  full  of  blood,  the 
larger  pulse-wave  sent  into  the  vessels  at  each 
ventricular  contraction  increases  the  amplitude 
of  the  pulse  in  the  arteries,  and  thus  brings 
about  a  more  efficient  self-massage  in  the  arterial 
walls,  and  consequently  a  more  efficient  return 
of  blood  and  lymph  from  the  veins  and  lym- 
phatics, which  accompany  the  arteries  in  their 
sheaths. 

The  heart  itself,  by  means  of  its  more  efficient 
self-massage,  gets  rid  of  its  waste  products,  is 
better  supplied  with  blood,  and  gradually 
becomes  stronger  and  stronger,  until  finally 
many  patients  who  seemed  moribund  recover 
under  the  influence  of  rest  and  massage  to  such 
an  extent  that  they  may  become  practically 
well  and  remain  so  for  years. 

But  it  is  not  only  on  the  heart  and  vessels 
that  the  influence  of  rest  and  massage  and  the 
consequent  improvement  of  the  circulation  is 
noticed.  On  account  of  the  increased  circula- 
tion through  the  muscles  waste  products  are 
more  thoroughly  oxidised,  and,  the  massage 
taking  the  place  of  exercise,  a  better  appetite 
for  food  is  produced,  whilst  the  diminished 
congestion  of  the  liver,  stomach,  and  intestines 
improves  digestion,  and  thus  lessens  flatulence. 
Massage  to  the  abdomen  aids  this  process;  it 


GRADUATED  EXERCISES  239 

tends  to  cause  expulsion  of  gas  from  the 
stomach  and  intestines,  and  thus  decreases  the 
mechanical  interference  which  the  abdominal 
distension  exerts  upon  the  lungs  and  heart. 
The  freer  circulation  tells  upon  the  kidneys  also. 
The  urine  becomes  more  abundant  in  quantity, 
albumen  disappears,  waste  is  more  freely 
eliminated,  and  absorption  goes  on  both  from 
the  inter-cellular  tissue  and  serous  cavities,  so 
that  the  oedema  of  the  limbs  and  fluid  accumu- 
lated in  the  peritoneal  or  pleural  cavities 
become  absorbed,  and  the  oedema,  ascites,  or 
pleural  effusion  disappears.  Pleural  effusion 
is,  of  course,  a  very  serious  complication  in 
valvular  disease,  encroaching,  as  it  does,  upon 
the  available  breathing  space,  and  its  appear- 
ance should  always  be  carefully  watched  for, 
more  especially  as  its  occurrence  is  often 
insidious.  It  is,  however,  less  common  and 
less  disturbing  than  abdominal  distention  by 
gas  or  water,  or  both. 

Graduated  Exercises. — For  patients  who  are 
so  ill  as  to  be  confined  to  bed  gentle  movements 
may  be  useful,  and  may  be  employed  along 
with  massage.  They  should  be  increased  very 
gradually.  For  example,  the  patient  may  bend 
one  finger  gently  against  resistance  the  first 
day  or  even  the  first  forenoon.  In  the  afternoon 
he  may  straighten  the  same  finger  against 
resistance.  Next  day  he  may  bend  two  fingers, 
and  in  the  afternoon  extend  two  fingers,  and  so 
on,  gradually  including  the  wrist,  the  fore-arm, 
and  even  the  arm.  The  resistance  should  at 
first  be  very  slight  indeed,  and  may  be  gradually 


240     TREATMENT  IN  CARDIAC  DISEASE 

increased  as  the  patient  can  bear  it.  Such 
gentle  movement  as  simply  flexing  a  finger 
might  seem  at  first  sight  to  be  useless,  but  if 
anyone  will  put  his  hand  upon  his  biceps  and 
get  someone  else  to  hold  his  finger  while  he 
flexes  against  resistance,  he  will  soon  discover  that 
it  is  not  merely  the  muscles  of  the  finger  alone 
that  are  in  action,  but  that  the  biceps,  and  even 
the  muscles  of  the  trunk  take  part  in  the  move- 


Fio.  76. — Pulse  tracing,  showing  the  effect  of  massage  and  graduated 
movements.  Each  tracing  is  taken  partly  with  a  slow  and  partly  with 
a  quick  movement  of  the  sphygmograph.  The  upper  shows  high  ten- 
sion and  a  feeble  heart ;  the  lower  shows  less  tension  and  a  stronger 
heart.  The  tracings  I  owe  to  the  kindness  of  Dr  Gustav  Hamel,  to 
whose  treatment  I  had  recommended  the  patient. 

ment.  The  effect  of  massage  and  exercises  on  the 
pulse  is  shown  by  the  tracing  above  (Fig.  76), 
where  the  high  tension  with  slight  movement  of 
the  radial  artery  is  converted  into  less  tension, 
quicker  contraction  of  the  heart,  and  more 
active  movement  of  the  vessel,  increasing  the 
self- massage  both  of  the  arteries  and  the 
heart. 

Oxygen. —  Inhalation  of  oxygen  certainly 
gives  great  help  in  severe  cases,  and  I  think  it 
is  possible  that  occasionally  the  deep  inhalations 


OXYGEN  241 

which  patients  take  when  they  are  inhaling  the 
oxygen  may  help  mechanically  by  producing 
self-massage  of  the  heart.  They  also  lessen  the 
viscosity  of  the  blood,  and  thus  aid  the  circula- 
tion. A  mask  is  usually  supplied  to  fit  over  the 
patient's  face,  but  many  patients  dislike  this  and 
prefer  a  tube  simply  placed  in  the  mouth,6  or 
a  funnel  held  before  the  nose. 

I  do  not  think  it  is  possible  to  give  too  much 
oxygen.  In  some  cases  I  have  given  it  for  more 
than  a  week  continuously  with  the  best  results. 
For  this  purpose  it  is  best  to  hang  a  funnel  at 
a  short  distance  above  the  patient's  nose  and 
mouth  so  that  the  oxygen  may  stream  con- 
stantly down  on  them. 

It  is  not  infrequently  desirable  to  administer 
nitrite  of  amyl,  or  iodide  of  ethyl,  along  with 
oxygen  to  patients  suffering  from  anginal  attacks 
or  spasmodic  asthma.  This  may  be  done  by 
putting  the  medicament  upon  a  piece  of  blotting- 
paper  or  cotton-wool  in  the  funnel  or  inhaler 
close  to  the  patient's  face.  The  inconvenience 
of  this  is  that  the  apparatus  is  apt  to  move  from 
its  position,  and  there  is  no  means  of  regulating 
the  strength  of  the  inhalation.  To  obviate  these 
inconveniences  a  bottle  has  been  made  for  me 
by  Messrs  Allen  &  Hanburys,  with  two  metal 
tubes  arranged  similarly  to  those  of  an  ordinary 
Woulfe's  bottle  (Fig.  77).  One  of  these,  how- 
ever, can  be  moved  up  and  down,  and  may  be 
fastened  by  means  of  a  screw,  as  shown  in  the 
illustration.  The  cotton-wool  or  blotting-paper, 
moistened  with  nitrite  or  iodide,  is  placed  in  the 
bottle.  At  first  the  movable  tube  is  drawn  well 


242     TREATMENT  IN  CARDIAC  DISEASE 

up,  so  that  as  the  oxygen  passes  through  it  over 
the  wool  the  vapour  is  dilute.  As  the  nitrite 
evaporates  the  tube  is  pushed  further  down  so 
as  to  go  closer  to  the  paper  or  wool,  and  thus  a 
stronger  vapour  is  obtained.  When  it  is  desired 
to  give  a  diffusible  stimulant,  ether  may  be 


FIG.  77. — Bottle  for  medicating  oxygen. 

employed  in  a  similar  way,  or  a  quantity  of 
rectified  spirit,  brandy,  or  whisky  may  be  poured 
into  the  lower  part  of  the  flask  and  oxygen 
allowed  to  bubble  through  it.  The  bottle  may 
also  be  used  simply  to  render  the  oxygen  warm 
and  moist.  In  this  latter  case  the  bottle  is  half 
filled  with  hot  water  and  placed  in  a  small  basin 
of  hot  water,  or  surrounded  by  hot  wet  flannels. 


NAUHEIM  TREATMENT  243 

In  some  cases  of  bronchitis  it  may  be  advisable 
to  add  to  the  hot  water  Friar's  balsam,  terebene, 
or  other  terebinthine  preparation.6 

In  very  bad  cases  artificial  respiration  may  be 
performed  with  oxygen.7  The  instrument  for 
this  purpose  is  shown  in  Fig.  78.  It  consists  of 
a  stopcock  of  peculiar  construction  which  is 
connected  by  an  india-rubber  tube  at  one  end 
to  a  cylinder  containing  oxygen,  and  at  the 
other  terminates  in  two  nozzles  which  pass 


ee  move  stopcock . 


FIG.  78.— Stopcock  for  artificial  respiration  with  oxygen. 

into  the  nostrils.  By  moving  a  short  lever  the 
nostrils  are  alternately  put  into  communication 
with  the  oxygen  cylinder  and  with  the  open  air, 
so  that,  by  moving  the  lever  alternately  back- 
wards, and  forwards,  artificial  respiration  is 
kept  up  with  the  minimum  of  exertion,  so  that 
it  may  be  continued  if  necessary  for  hours. 

Nauheim,  Treatment. — For  cases  of  weak 
heart  and  tendency  to  venous  engorgement 
the  treatment  by  baths  and  exercises  is  also 
useful.  The  system  of  applying  them  has  been 
well  worked  out  by  the  brothers  Augustus  and 


Theodore  Schott,  at  Nauheim,  and  the  treat- 
ment is  often  known  now  as  the  "  Nauheim " 
treatment.8  At  Nauheim  the  water  as  it  issues 
from  the  springs  is  very  highly  charged  with 
carbonic  acid,  but  this  is  allowed  to  escape,  and 
the  water  to  become  still,  for  the  baths  which 
are  given  at  first,  and  it  is  only  in  the  later  baths 
that  the  effervescent  water  is  employed. 

Baths. — Baths  are  usually  employed  daily  for 
three  days,  then  omitted  for  one  day,  during  a 
course  of  three  to  six  weeks,  or  even  longer, 
according  to  the  condition  of  the  patient.  The 
bath  at  first  lasts  only  about  six  minutes,  at  a 
temperature  of  95°.  The  duration  is  then 
increased  to  eight  or  ten  minutes,  and  the 
temperature  is  lowered  to  92°.  They  are  then 
strengthened  further  with  the  mother  liquor 
obtained  by  evaporating  the  ordinary  water. 
The  duration  is  gradually  increased  to  fifteen 
or  twenty  minutes  and  the  temperature  lowered 
as  far  as  82°.  Immediately  after  the  bath  the 
patient  is  rubbed  dry  with  hot  sheets  by  an 
attendant,  and  then  must  rest  for  at  least  an 
hour.  The  effect  of  the  baths  is  generally 
somewhat  to  slow  the  pulse.  This  effect  on  the 
pulse-rate  is  not  so  marked  as  that  on  its  quality, 
for  they  render  it  much  fuller  and  softer  (see 
Figs.  79-84,  pp.  246-7).. 

On  alternate  days  movements  may  be  used, 
or  daily,  according  to  the  patient's  condition. 
I  give  here  a  list  of  the  movements,  which 
Professor  Schott  at  Nauheim  kindly  got  his 
attendant  to  show  me.  Six  to  twelve  of  these 
movements  may  be  given  at  a  time,  and  they 


BATHS— EXERCISES  245 

should  be  selected  so  that  alternate  movements 
shall  affect  different  sets  of  muscles. 

Exercises. — The  essential  part  of  these  move- 
ments is  that  the  movement  shall  be  slow  and 
regular,  and  that  each  movement  shall  be  fully 
carried  out.  The  body  should  be  held  upright, 
the  joints  should  be  kept  straight,  and  the  resist- 
ance applied  should  not  be  sufficiently  great  to 
cause  any  tremor  of  the  limbs  or  shortness  of 
breath  in  the  patient.  The  resistance  may 
either  be  applied  by  the  patient  himself  putting 
into  action  the  opposing  muscles  to  those  which 
effect  the  movement,  or  by  an  attendant  or 
friend  gently  opposing  the  movements. 

I.  The  arms  are  to  be  raised  slowly  outwards 
from  the  side  until  they  are  on  a  level  with  the 
shoulder.     After  a  pause  they  should  be  slowly 
lowered. 

II.  The  body   should   be   inclined    sideways 
as   much   as   possible    towards   the   right,  and 
then  to  the  left. 

III.  One  leg   should  be   extended  as  far  as 
possible   sideways  from  the   body,  the  patient 
steadying  himself  by  holding   on   to   a   chair. 
The   leg   is   then   dropped   back.      The    same 
movements  are  repeated  by  the  other  leg. 

IV.  The  arms  are  raised  in  front  of  the  body 
to  a  level  with  the  shoulder,  and  then  put  down. 

V.  The  hands  are  rested  on   the   hips,  and 
the  body  is  bent  forwards  as  far   as   possible, 
and  then  raised  to  the  upright  position. 

VI.  One  leg  is  raised  with  the  knee  straight 
forwards  as  far  as  possible,  then  brought  back. 
This  movement  is  repeated  with  the  other  leg. 


246    TREATMENT  IN  CARDIAC  DISEASE 


Fio.  79.— Tracing  from  the  pulse  of  a  patient,  aged  62,  with  a  gouty  kidney 
and  failing  heart.  This  tracing  and  the  five  following  from  the  same 
patient  show  the  effect  on  the  pulse  of  exercises  and  baths. 


J      SSJ 


<7  f    SI -10-98.   after      exercise   3?oz 


Fio.  80  —  Effect  of  exercise. 


GF   28-10-98.   before  Is-1  bath    3zo7. 


Fio.  81.— Before  first  bath. 


EFFECTS  OF  BATHS 


247 


FIG.  82.— Effect  of  one  bath. 


PIG.  83.—  Effect  of  saline  and  effervescing  baths. 


"'.F.  10-12-98  after   19^    bath 


Fid.  84.— Effect  of  nineteen  baths. 


248     TREATMENT  IN  CARDIAC  DISEASE 

VII.  With  the  hands  on  the  hips,  the  body 
is  twisted  round  as  far  as  possible  to  the  right, 
and  then  again  to  the  left. 

VIII.  With  the  hands  resting  on  a  chair  and 
the  back  stiff  and  straight,  each  leg  is  raised 
as  far  as  possible  backwards,  first  one  and  then 
the  other. 

IX.  The   arms   are    extended  and   the   fists 
supinated.     The  arms  are  then  moved  first  out- 
wards, next  inwards  at  the  height  of  the  body. 

X.  Each  knee  is  first  raised  as  far  as  possible 
to  the  body,  and  then  the  leg  extended. 

XI.  This   movement    is    the    same    as    IX.V 
but  with  the  fists  pronated. 

XII.  Each  leg  is  bent  backwards  from  the 
knee  and  then  straightened. 

XIII.  Each    arm   is   bent  and   straightened 
from  the  elbow. 

XIV.  The  arms  are  brought  from  the  sides 
forwards    and   upwards,  then   downwards  and 
back  as  far  as  they  will  go,  the   elbows   and 
the  hands  being  straight. 

XV.  The   arms  are  put  at  a  level  with  the 
shoulder,    and     then     bent  *  from    the     elbow 
inwards  and  again  extended. 

XVI.  With   the   arms  in  front   at  the  level 
of  the   shoulder  and  the  hands   stretched,  the 
arms    are    opened    out    sideways     and    then 
brought  together. 

XVII.  The  arms  are  bent  from  the   elbow 
outwards  and  extended. 

There  should  be  a  pause  of  half  a  minute 
between  each  successive  movement,  such  as 
raising  the  arms  and  lowering  them,  and  a 


AFTER-CURE  249 

pause  of  one  or  two  minutes  between  the 
movements  of  different  kinds,  such  as  I. 
and  II. 

Personal  Observations  on  the  Nauheim 
Treatment. — The  results  of  observations  made 
upon  myself  during  a  mild  course  of  five  weeks 
at  Nauheim  under  the  care  of  Professor  Schott 
were : — 

The  pulse-rate  was  little  affected  either  by 
baths,  massage,  or  movements,  but  each  of 
these  means  of  cure  altered  its  character, 
rendering  it  fuller  and  softer. 

The  blood-pressure  was  little  affected  either 
by  baths  or  massage,  but  was  almost  invariably 
lowered  5  mm.  by  exercises. 

The  result  in  five  weeks  was  increase  of 
strength,  greater  ability  for  exercise,  dimin- 
ished dilatation  of  the  heart,  as  ascertained 
by  percussion  and  reduction  of  the  blood-pressure 
to  the  normal.9 

After-Cure. — After  the  course  is  over  it  is 
advisable  for  the  patient  to  go  to  some  place 
for  an  after-cure,  where  he  can  follow  up  the 
treatment  by  graduated  exercise. 

The  best  after-cure  consists  in  daily  walks  in 
which  both  the  distance  travelled  and  the  steep- 
ness of  the  road  are  very  gradually  increased, 
great  care  being  taken  not  to  cause  exhaustion 
or  strain,  which  might  undo  all  the  good 
obtained  from  the  cure.  Walks  are  laid  out  for 
this  purpose  very  carefully  at  Badenweiler,  in 
Germany ;  but  there  are  a  great  number  of 
places  both  at  home  and  abroad  where  suit- 
able conditions  can  be  found  with  walks  on 


250    TREATMENT  IN  CARDIAC  DISEASE 

the  flat  and  more  or  less  steeply  inclined  along 
a  hillside.  In  Switzerland  especially  there  are 
numerous  places  of  this  sort,  and  the  fresh  air 
there  seems  to  have  an  invigorating  action. 
Many  people  with  cardiac  disease  cannot  go 
without  discomfort  to  a  height  exceeding  2000 
feet,  while  others  feel  better  at  greater  eleva- 
tions, though  the  number  of  those  who  care 
to  go  as  high  as  7000  feet  is  small,  and  if  the 
arterial  tension  is  high  such  altitudes  should 
be  avoided. 

Oertel's  Treatment.  —  This  treatment  by 
graduated  exercise  is  often  known  as  Oertel's. 
The  principles  upon  which  it  depends  are — (i) 
That  the  cardiac  symptoms  are  due  to  dispro- 
portion between  the  force  of  the  heart  and 
the  resistance  it  has  to  overcome ;  and  (2)  this 
disproportion  is  to  be  remedied  by  dietetics 
and  by  exercise,  consisting  chiefly  of  graduated 
walking  uphill.10 

The  dietetic  rules  are — (i)  Give  such  food  as 
will  strengthen  the  cardiac  muscle ;  and  (2) 
diminish  the  amount  of  liquid  consumed,  in 
order  to  reduce  the  mass  of  circulating  blood. 

The'  exercises  are  intended  to  promote 
elimination  of  liquid,  especially  through  the 
lungs  and  skin,  and  to  increase  the  nutrition 
and  activity  of  the  heart.  In  aortic  regurgita- 
tion,  Dr  Schott  considers  that  the  work  of  the 
heart  is  easier  when  there  is  abundance  of  blood 
to  make  up  for  the  loss  in  the  general  circula- 
tion sustained  by  regurgitation  during  the 
diastole.  He,  therefore,  advises  a  very  full 
diet;  but  in  mitral  disease,  where  the  patient, 


OERTELS  TREATMENT  251 

on  account  of  breathlessness,  can  move  less  than 
a  healthy  person,  he  advises  a  sparing  diet.  In 
chronic  myocarditis,  where  albumen  is  required, 
but  not  nuclein,  butcher's  meat  should  be  given 
sparingly,  but  milk  and  plasmon  freely.  In 
aortic  disease  he  allows  two  pints  of  fluid  a 
day,  and  as  much  as  three  pints  if  the  weather 
be  hot ;  but  if  there  is  any  interference  with  the 
pulmonary  circulation,  as  shown  by  shortness  of 
breath,  he  only  allows  between  a  pint  and  a 
half  and  two  pints.  In  mitral  disease  he  only 
allows  about  a  pint  and  a  quarter  to  a  pint  and 
a  half. 

The  exercise  consists  in  gentle  walking  up 
graduated  slopes.  The  first  walk  is  taken  upon 
a  very  gentle  slope,  and  only  for  a  short  distance. 
This  is  increased  daily,  and  when  the  patient 
can  walk  on  the  level  or  gentle  slope  without 
shortness  of  breath,  he  walks  up  a  somewhat 
steeper  grade.  The  steepness  of  the  ascent  and 
the  lengths  of  the  walks  are  gradually  increased 
as  the  patient's  heart  will  bear  it11 

Exercise.  Games.  Sports. — The  questions 
are  constantly  asked  by  patients  suffering  from 
cardiac  disease :  "  What  exercise  may  I  take  ? 
May  I  play  tennis  or  golf?  May  I  cycle,  fish, 
shoot,  ride  or  hunt?"  The  answers  to  these 
questions  differ  not  only  according  to  the  nature 
and  extent  of  the  cardiac  disease,  but  according 
to  the  patient's  temperament  and  disposition ; 
for  while  one  patient  will  do  exactly  as  he  is 
told,  another  will  be  timorous  and  do  too  little, 
while  a  third  will  interpret  any  liberty  that  is 
allowed  him  in  the  very  widest  sense,  and  make 


252     TREATMENT  IN  CARDIAC  DISEASE 

efforts  that  are  not  only  foolish  but  dangerous 
to  his  life.  The  great  rule  is  to  take  as  much 
exercise  as  possible  without  causing  strain  or 
bringing  on  much  fatigue.  When  fatigue  comes 
on,  the  exercise  should  stop.  If  his  exercise 
should  take  the  patient  away  from  home,  he 
must  always  remember  that  he  has  to  get  back, 
whether  he  be  walking,  riding,  or  cycling,  and 
must  turn  back  in  good  time  so  that  he  shall 
not  be  obliged  to  continue  the  exercise  after  he 
begins  to  feel  tired.  All  severe  sudden  strains 
should  be  avoided,  such  as  riding  a  bicycle  up  hill 
or  in  face  of  a  wind,  riding  a  restless  horse,  taking 
a  big  jump  in  hunting  or  playing  lawn-tennis, 
cricket,  or  golf  in  a  match  where  the  player  feels 
that  he  must  do  the  best  he  canforhis  side  regard- 
less of  the  consequences.  The  same  is  the  case  in 
rowing.  Paddling  in  a  small  boat  is  sometimes 
very  good  for  slight  cardiac  cases,  for  it  gives 
amusement  and  just  enough  exercise  to  benefit 
the  circulation  without  causing  strain.  For 
people  who  require  exercise  and  have  very  little 
time  to  take  it,  a  rowing  machine  is  good  because 
the  resistance,  rate  of  movement,  and  duration 
of  the  exercise  can  be  accurately  adjusted. 

Milk  Diet  and  Chloride-free  Pood. — Lately 
a  great  deal  of  attention  has  been  given, 
especially  in  France,  to  the  effect  of  chlorides 
upon  transudation  from  the  vessels  into  the 
tissues.12  Chlorides  appear  to  favour  this,  and 
therefore,  although  they  may  be  useful  in 
health,  they  are  disadvantageous  in  dropsy, 
and  accordingly  a  diet  containing  only  a  small 
quantity  of  chlorides  is  used.  Calcium  and 


MILK  DIET-  CHLORIDE-FREE  FOOD    253 

its  salts  appear  to  have  a  contrary  action,  and 
rather  to  diminish  transudation.  The  amount 
of  chlorides  in  milk  is  not  great,  the  quantity 
of  calcium  is  considerable,13  and  the  lactose 
appears  to  have  a  diuretic  action ; u  so  that 
frequently  we  notice  patients  suffering  from 
mitral  disease  when  put  to  bed  with  entire  rest, 
with  massage,  with  an  entirely  milk  diet,  just 
as  if  they  were  typhoid  patients,  and  with 
a  pill  of  digitalis,  blue  pill  and  squill,  fre- 
quently improve  with  great  rapidity.  But  a 
milk  diet  does  not  always  suit;  and  conse- 
quently bread  made  with  sugar  instead  of  salt, 
farinaceous  preparations  also  made  with  sugar 
and  without  salt,  and  boiled  meat  without  salt, 
but  with  sweetened  tomato  sauce  or  some  such 
condiment  to  make  it  pleasant,  and  eggs,  either 
boiled  without  salt  or  in  the  form  of  a  sweet 
omelette,  and  plasmon,  may  all  be  used.  I 
have  only  tried  this  in  a  few  cases,  but  certainly 
the  treatment  has  appeared  satisfactory. 

Sugar  Treatment  of  Failing  Heart. — The 
nutritive  power  of  sugar  has  been  utilised  in 
cases  of  cardiac  weakness  by  Dr  Goulston 15  and 
by  Dr  Carter 16  (vide  p.  287). 

Local  Modification  of  the  Circulation.  Heat 
and  Cold.  —  We  have  various  methods  of 
modifying  the  circulation  locally.  In  local  in- 
flammations, aconite  seems  to  be  useful, 
and  during  its  administration  the  local  in- 
flammation frequently  subsides,  the  pain  dis- 
appearing, the  redness,  swelling,  and  heat  of 
the  part  diminishing.  We  may  modify  the 
local  circulation  in  inflammation  either  by  heat 


254     TREATMENT  IN  CARDIAC  DISEASE 

or  cold.  If  the  inflammation  be  situated  in 
a  place  where  the  tissues  are  yielding,  heat 
frequently  relieves  it  most ;  but  if  the  tissues  are 
unyielding,  as,  for  example,  where  the  inflam- 
mation occurs  at  the  root  of  a  tooth  or  under  a 
hard  fascia,  heat  increases  the  pain,  while  cold 
relieves  it.  The  explanation  of  this  is  obvious. 
Heat  tends  to  cause  local  dilation  of  the  vessels, 
and  if  the  nerves  which  run  alongside  them  are 
in  an  unyielding  sheath,  the  dilated  vessels 
press  more  upon  them  and  increase  the  pain ; 
whereas  if  the  tissues  are  yielding  all  round,  the 
collateral  circulation  is  increased,  and  the 
pressure  of  blood  in  the  inflamed  area  is 
lessened.  If  the  nerves  and  vessels  are  both 
confined  in  an  unyielding  sheath,  the  applica- 
tion of  cold  tends  to  cause  contraction  of  the 
vessels,  and,  by  diminishing  their  calibre,  to 
lessen  pressure  upon  the  nerves  and  ease  the 
pain.  The  local  application  of  heat  may  induce 
a  pretty  extensive  dilatation  of  the  vessels  ; 
for,  on  putting  my  feet  into  a  bath  of  hot  water, 
I  have  sometimes  observed  increased  pulsation 
of  the  femoral  arteries.  The  local  application 
of  cold  in  the  case  of  an  artery  will  cause  it  to 
contract,  and  lessen  the  circulation  in  the  distal 
part ;  so  that  if  a  cold  bandage  be  applied  over 
the  middle  of  the  arm,  the  radial  artery  will 
beat  less  strongly.17  By  putting  on  a  cold 
bandage  covered  with  oil-silk  a  gentle  warmth 
of  the  surface  is  produced,  which  seems  to  have 
a  quieting  effect  upon  the  circulation,  and 
lessens  the  pain  from  inflammation,  as  is 
evident  from  its  use  in  various  local  lesions,  and 


HEAT  AND  COLD— POULTICES         255 

perhaps  most  markedly  when  applied  to  the 
throat  in  cases  of  pharyngitis  and  tonsillitis. 
A  large  wet  compress  of  this  sort  applied 
to  the  abdomen  is  sometimes  very  useful  in 
cases  of  sleeplessness,  as  it  tends  to  draw 
away  the  blood  from  the  brain  and  allow  the 
nerve  cells  to  become  quiet.  Warmth  to  the 
inside  of  the  stomach  has  a  similar  action,  and 
warm  food  will  often  tend  to  produce  sleep. 
The  food  must,  however,  not  be  too  warm,  as 
otherwise  the  heat  will  pass  through  the  dia- 
phragm, and  by  its  local  stimulating  action  on 
the  heart  will  increase  the  force  of  the  pulse, 
and  by  driving  more  blood  to  the  brain,  lessen 
the  tendency  to  sleep  instead  of  increasing  it. 

Poultices. — These  applications  often  give  the 
greatest  possible  relief  in  pain  due  to  pleurisy 
or  pericarditis,  as  well  as  to  pains  of  a  colicky 
nature.  They  are  usually  made  of  crushed 
linseed,  bread-crumb,  arrowroot,  or  oatmeal, 
and  some  mustard  flour  is  often  added  to 
them.  They  are  frequently  applied  to  the 
skin  with  nothing  between  them  and  it  except 
perhaps  a  layer  of  muslin.  In  the  case  of 
poultices  of  mustard  flour  alone  or  of  poultices 
in  which  its  irritant  action  is  desired,  this  is 
quite  right,  and  also  where  linseed  poultices  are 
used  for  their  local  soothing  and  demulcent 
action  on  wounds  or  ulcers.  But  this  method 
is  not  the  best  where  poultices  are  required  to 
soothe  pain  inside  the  thorax  or  abdomen.18 
For  if  we  apply  the  poultice  directly  to  the  skin 
we  either  burn  it  and  cause  great  pain  to  the 
patient,  or  we  must  wait  until  it  is  cool  enough 


256    TREATMENT  IN  CARDIAC  DISEASE 

to  be  borne,  and  then  much  of  its  warmth  is 
lost  But  if  two  layers  of  flannel  be  interposed 
between  the  poultice  and  the  skin  it  may  be  put 
on  as  hot  as  it  can  possibly  be  made. 

A  convenient  way  of  making  a  poultice  is  to 
prepare  a  flannel  bag  about  twelve  inches  by 
eight ;  this  should  be  closed  at  three  edges  and 
open  at  the  fourth ;  one  side  of  it  should  be 
about  one  inch  or  one  inch  and  a  half  longer 
than  the  other,  and  it  is  convenient  also  to  have 
four  tapes  attached  at  the  points  which  form  the 
corners  when  the  bag  is  closed,  in  order  to  keep 
the  poultice  in  position.  Besides  this,  another 
strip  of  flannel  should  be  prepared  of  the  same 
breadth  as  the  length  of  the  bag,  and  long 
enough  to  wrap  round  it  once  or  oftener. 
Crushed  linseed,  bowl,  and  spoon  should  then 
be  got  together,  and  the  spoon  and  bowl 
thoroughly  heated  by  means  of  boiling  water ; 
the  poultice  should  then  be  made  with  perfectly 
boiling  water,  and  rather  soft.  As  soon  as 
it  is  ready,  it  should  be  poured  into  the  bag, 
previously  warmed  by  holding  it  before  the 
fire;  the  flap  which  is  formed  by  the  longest 
side  of  the  bag  should  now  be  turned  down  and 
fastened  in  its  place  by  a  few  long  stitches  with 
a  needle  and  thread ;  it  should  then  be  quickly 
wrapped  in  the  strip  of  flannel  (also  previously 
warmed),  and  fastened  in  situ,  if  necessary,  by 
means  of  the  tapes.  It  may  be  covered  outside 
with  a  sheet  of  cotton  wool.  In  this  way  the 
poultice  may  be  applied  boiling  hot  to  the  skin 
without  burning ;  the  two  layers  of  flannel 
which  are  at  first  dry  allow  the  heat  to  pass 


LOCAL  BLEEDING  257 

very  gradually  indeed  to  the  skin ;  as  the 
moisture  of  the  poultice  soaks  through  them, 
they  become  better  conductors,  and  the  heat 
passes  more  quickly,  but  the  increase  is  so 
gradual  as  not  to  cause  any  painful  sensations 
whatever,  but  only  one  of  soothing  and  comfort. 
The  poultice  also  naturally  keeps  much  longer 
hot,  and  the  necessity  for  changing  it  arises 
much  less  frequently. 

An  india-rubber  bag  laid  over  one  or  two 
layers  of  moist  flannel  is  sometimes  a  convenient 
substitute  for  a  poultice. 

Hot  Air  Bath. — By  placing  an  arm  or  leg  in 
a  hot  air  bath  at  240°  F.  the  temperature  of  the 
whole  body  may  be  raised  and  cardiac  pain 
sometimes  diminished.  Of  course  the  limb 
must  be  carefully  protected  by  cotton  wool  or 
by  some  other  material  which  does  not  conduct 
heat  easily,  so  as  to  protect  it  from  being 
burned.19 

Local  Bleeding. — A  means  of  influencing  the 
circulation  locally,  which  was  formerly  much 
employed,  but  has  now  to  a  great  extent  fallen 
into  disuse,  is  the  application  of  leeches  and 
cupping.  The  relief  which  is  obtained  by  the 
application  of  half  a  dozen  leeches  to  the  side, 
in  cases  of  severe  pleurisy,  is  very  extra- 
ordinary ;  and  it  is  difficult  indeed  to  see 
how  the  comparatively  small  quantity  of  blood 
which  they  extract  should  relieve  the  patient 
so  much ;  but  there  can  be  no  doubt  about 
the  fact  that  the  relief  they  afford  is  enormous. 
Their  application  over  the  mastoid  process  in 
severe  headache  or  in  meningitis,  and  over 


258     TREATMENT  IN  CARDIAC  DISEASE 

the  cardiac  area  in  pericarditis  or  the  liver 
in  hepatitis,  especially  if  accompanied  with 
perihepatitis,  is  very  useful.  Wet  cupping 
over  the  kidneys  in  acute  nephritis,  and  over 
the  back  in  suffocative  bronchitis,  is  sometimes 
attended  with  marked  amelioration  of  the 
symptoms.  It  is  not  simply  the  removal  of 
blood  that  produces  this  effect,  because  dry 
cupping,  where  no  blood  is  removed,  is 
frequently  of  service.  In  dry  cupping  the 
beneficial  result  may  be  partly  due  to  the 
withdrawal-  of  blood  to  the  skin  and  sub- 
cutaneous tissue.  It  may  also  be  due  to  a 
reflex  effect  of  the  stimulus  upon  the  circula- 
tion, both  local  and  general,  and  it  may  possibly 
be,  to  some  extent,  a  form  of  serum  thera- 
peutics, as  the  fluid  which  exudes  into  the 
tissues  after  the  application  of  the  cups  may 
undergo  some  alteration  which  imparts  to 
it  a  curative  action  after  its  reabsorption. 
Any  explanation  of  the  mode  of  action,  how- 
ever, is  at  present  hypothetical,  and  we  are 
obliged  to  be  content  with  knowing  what  the 
effects  are  without  understanding  how  they 
are  produced. 

General  Bleeding. — Bleeding  from  the  arm 
is  a  remedy  which  is  now  too  little  used. 
In  the  case  of  angina  pectoris,  in  which  I 
used  nitrite  of  amyl  for  the  first  time,  small 
bleedings  of  three  or  four  ounces  were  the 
only  thing  which  eased  the  pain  before  the 
nitrate  was  employed,  and  even  after  its 
employment  bleeding  from  the  arm  benefited 
the  patient.  In  engorged  conditions  of  the 


METHOD  OF  BLEEDING  259 

right  side  of  the  heart,  whether  due  to  mitral 
incompetence  or  pulmonary  affections,  blood- 
letting not  only  relieves  the  symptoms,  but 
may  save  the  patient's  life. 

Method  of  Bleeding. — Bleeding  used  at  one 
time  to  be  practised  by  barbers  and  black- 
smiths, and  was  so  much  in  fashion  that  it 
was  often  used  every  spring  as  a  matter  of 
routine  whether  the  person  bled  was  ill  or 
not.  Its  abuse  led  to  its  disuse,  and  now  it 
is  so  little  used  that  many  men  in  practice  have 
never  bled  a  patient  and  hardly  know  how 
to  do  it  or  what  instrument  to  use.  In  my 
opinion  it  should  not  be  done  with  a  bistoury, 
but  with  an  old-fashioned  lancet,  which  is  much 
better.  A  bandage  is  put  tightly  round  the 
upper  arm  so  as  to  prevent  the  return  of  venous 
blood  and  a  tight  roll  of  paper,  a  stick,  or 
something  similar  put  into  the  patient's  hand 
so  that  he  may  alternately  grasp  it  firmly 
and  loosely,  and  by  the  motion  of  his  muscles 
drive  the  blood  into  the  veins.  The  striped 
pole  which  is  still  used  as  a  sign  by  barbers 
represents  the  stick  which  they  used  in  bleeding 
and  the  stripes  round  it  represent  the  bandage. 
When  the  veins  stand  out  well  a  slight  cut  is 
made  with  the  lancet  into  either  the  median 
cephalic  or  median  basilic,  care  being  taken 
that  the  cut  skin  does  not  become  displaced, 
for  the  cut  in  it  and  in  the  vein  must  coincide. 

As  the  blood  spurts  from  the  distended  vein 
a  vessel  must  be  held  in  such  a  manner  as  to 
catch  it,  for  otherwise  both  clothes  and  bed- 
clothes may  be  much  soiled. 


260    TREATMENT  IN  CARDIAC  DISEASE 

If  blood  refuses  to  flow,  as  it  does  when 
patients  are  too  far  gone,  the  forearm  may 
be  squeezed  and  rubbed  in  an  upward  direction, 
and  oxygen  given  to  aerate  the  blood  (vide 
p.  240). 

Usually  the  abstraction  of  ten  or  fifteen 
ounces  is  sufficient  at  a  time,  for  it  is  not  the 
mere  quantity  abstracted  that  does  the  good. 

In  cases  of  very  high  tension  I  believe  that 
the  repeated  abstraction  of  small  quantities  of 
blood  from  time  to  time  may  do  much  good, 
and  in  my  paper  on  the  use  of  nitrite  of  amyl 
in  angina  pectoris  in  the  Lancet  for  2/th  July 
1867,  I  recommended  that  in  severe  cases  of 
this  disease,  in  addition  to  the  use  of  nitrite 
of  amyl  in  a  paroxysm,  bleeding  should  be 
performed  about  every  fortnight.20  Such 
frequent  bleedings  as  this,  though  they  were 
the  only  means  of  relieving  my  patient  before 
I  used  the  nitrite,  are  probably  unnecessary 
in  most  cases  now,  as  we  now  know  other 
means  of  reducing  tension. 

Tapping  for  CEdema. — The  simplest  way  of 
tapping  the  legs  for  oedema  is  simply  to  run 
an  ordinary  sewing  needle  into  them  in  a 
number  of  places  and  then  cover  them  with 
absorbent  cotton-wool,  which  absorbs  the  serum 
as  it  exudes.  The  legs  should  be  previously 
washed  with  some  disinfecting  solution  and 
the  needle  also  rendered  aseptic.  Some 
prefer  a  triangular  to  a  sewing  needle,  and 
sometimes  fine  cannulae  introduced  by  a  trocar 
and  fitted  with  a  long  india-rubber  tube  to  carry 
off  the  fluid  are  preferable  to  either. 


TAPPING  261 

Tapping  for  Ascites. — This  is  often  delayed 
unduly  by  the  patient's  fear  of  it,  but  this  may 
often  be  overcome  by  using  a  very  small  trocar 
and  cannula  from  TVth  to  |th  of  an  inch  in 
internal  diameter.  Before  introducing  this,  three 
or  four  feet  of  fine  rubber  tubing  should  be  tied 
to  the  outer  end  of  the  cannula,  and  pulled  down 
over  the  opening.  The  trocar  is  then  pushed 
through  the  rubber  into  the  cannula.  Before 
this  is  done  the  cannula  and  tubing  may  be  filled 
with  disinfecting  solution,  e.g.,  of  carbolic  acid  i 
in  20,  and  the  tubing  tied  in  a  knot  at  its  lower 
end  to  prevent  the  fluid  escaping.  The  skin  is 
then  disinfected,  and  if  the  patient  is  very  sensi- 
tive it  may  be  anaesthised  by  ether  spray,  cocaine 
or  novocaine.  The  trocar  is  then  pushed  through 
the  abdominal  parietes,  the  knot  in  the  tubing 
undone  and  the  trocar  withdrawn.  The  elas- 
ticity of  the  rubber  closes  up  the  hole  made  in 
it  by  the  trocar  and  no  fluid  comes  through  it, 
but  the  carbolic  solution  at  once  begins  to  flow 
into  a  pail  or  basin  on  the  floor,  in  which  some 
of  the  same  solution  may  also  be  placed.  On 
account  of  the  small  diameter  of  the  tube  the 
fluid  flows  out  slowly,  and  this  has  the  advantage 
of  lessening  any  chance  of  syncope.  If  the 
medical  attendant  had  to  stay  a  long  time  it 
would  have  the  grave  disadvantage  of  interfering 
seriously  with  his  other  work.  But  this  is  un- 
necessary, for  if  the  tube  is  properly  fastened  to 
the  abdominal  wall  it  may  be  left  for  a  couple 
of  hours  without  injury  to  the  patient  and  even 
without  his  being  conscious  of  its  presence.  The 
best  way  of  doing  this  is  by  strips  of  adhesive 


262     TREATMENT  IN  CARDIAC  DISEASE 

plaster  with  two  cuts  in  each  piece  so  that  its 
middle  can  be  raised  and  the  tubing  passed  under 
it.  The  strip  is  then  fixed  to  the  abdominal 
wall  and  keeps  the  tubing  perfectly  in  position. 
If  necessary  more  than  one  strip  may  be  used 
(Fig.  85). 


Pio.  85.— Diagram  of  the  method  of  tapping  in  .incites  and  fixing  the  tubing 
described  in  the  text. 


Plasters  over  the  Heart. — These  probably 
act  reflexly,  but  we  do  not  know.  There  can 
be  little  or  no  doubt,  however,  of  the  marked 
benefit  which  results  from  local  applications  over 
the  cardiac  region.  When  the  heart  is  excited 
by  emotion,  the  natural  tendency  is  to  place  the 
hand  over  the  heart,  in  order,  as  the  phrase  goes, 
"to  still  its  beating."  The  pressure  of  the  hand 
over  the  cardiac  region  certainly  tends  to  quiet 


PLASTERS— BLISTERS  263 

palpitation,  and  the  same  result  is  obtained, 
even  to  a  greater  extent,  by  permanent  pressure 
from  the  application  of  a  plaster  over  this  region. 
The  plaster  may  be  simply  adhesive  ;  but  I  think 
the  use  of  extract  of  belladonna  is  something 
more  than  a  prejudice,  and  a  belladonna  plaster, 
I  think,  really  has  a  more  powerful  action  as  a 
cardiac  sedative  than  a  merely  adhesive  plaster. 
A  good  deal  depends  upon  the  way 
the  plaster  is  applied.  It  is  best 
not  to  have  it  too  small,  and  in  the 
case  of  women  it  ought  to  be  cut  like 
the  pattern  which  I  show  you,  so  that  it  may  fit 
over  the  breast.  An  india-rubber  bag,  filled 
with  crushed  ice,  applied  over  the  cardiac  region 
sometimes  quiets  excessive  cardiac  action;  or, 
in  place  of  it,  a  tube  of  india-rubber,  coiled  round 
and  round,  so  as  to  form  a  flat  plate  through 
which  cold  water  may  be  passed  in  a  continuous 
stream,  may  have  a  similar  action.  When  the 
action  of  the  heart  is  feeble,  a  bag  filled  with  hot 
water,  or  a  warm  poultice,  a  warm  fomentation,  or 
a  turpentine  stupe,  may  stimulate  its  action.  In 
one  case  of  cardiac  disease  I  have  seen  ammonia 
liniment  rubbed  over  the  cardiac  region  for  the 
relief  of  pain  bring  on  such  palpitation  as  to 
cause  very  great  inconvenience  to  the  patient,  and 
to  necessitate  the  relinquishing  of  the  remedy. 

Blisters. — In  pericarditis  blisters  near  or  over 
the  cardiac  region  are  sometimes  very  useful 
both  in  checking  the  inflammation  at  its  very 
commencement21  and  in  causing  absorption  of 
fluid  effused  into  the  pericardium  in  acute 
pericarditis.  Before  the  introduction  of  salicin, 


264  LITERATURE 

the  common  method  of  treating  inflamed  joints 
in  acute  rheumatism  was  nearly  to  surround  the 
limb,  just  above  and  below  the  joint,  by  a  blister 
about  an  inch  wide.  This  proceeding  may 
possibly  be  regarded  as  a  form  of  serum  thera- 
peutics, as  it  caused  the  urine  previously  acid  to 
become  alkaline.22 

LITERATURE. 

1  Lauder   Brunton,   "On   the   Use  of  Rest  in  Cardiac 

Affections,"  Practitioner,  1893,  vol.  li.,  p   190. 

2  Lauder   Brunton,  "  On  Posture  and   its   Indications," 

Lancet,  2nd  July  1892,  p.  12. 

8  J.  Lionel  Stretton,  Brit.  Med.Journ.,  1904,  vol.  ii.,  p.  927. 
4  Lauder  Brunton,  Practitioner,  vol.  li.,  p.  202. 

6  Brit.  Med.  Journ.,  23rd  January  1892,  p.  172. 
0  Lancet,  5th  April  1913,  vol.  i.,  p  970. 

7  Lauder   Brunton,   Atte    delP    XL    Congresso    Medico 

Internationale,  Roma,  29  Marzo-5th  Aprile  1894; 
and  Brit.  Med.  Journ.,  I7th  February  1912,  p.  534. 

8  Schott,  Berl.   klin.    Wochenschr.,    1885  ;    Th.   Schott, 

Berl.  klin.  Wochenschr.,  1880 ;  Heilfactoren  Bad 
Mannheims,  1900,  Wiesbaden  ;  Bergmann,  Ueber- 
anstrengung  des  Herzens,  1898  (Wiesbaden  :  Berg- 
mann);  Berl.  klin.  Wochenschr.,  1896,  No.  21; 
Literature,  etc.,  Eulenburg's  Realencyclopedie,  2nd 
ed.,  vol.  xii. ;  Verhand.  d.  XVI.  Kongr  inn.  Med., 
Wiesbaden,  1898  ;  Med.  Rec.,  New  York,  1901,  29th 
June,  p.  1028. 

9  Lauder  Brunton,   "  Memoires   en   1'honneur  du  Prof. 

Raphael  Lepine,"  Rev.  de  Med.,  October  1911,  p.  125 
et  seq. 

10  M.   J.   Oertel,  Therapie  des  Kreisl.  Storungen,  1884 

(Leipzig  :  Vogel) ;  also  v.  Ziemssen's  Handbook. 

11  Oertel,  Ueber  Terrain  Curorte,  1886  (Leipzig  :  Vogel). 

12  Vaquez,  Bull,  de  la  Soc.  Med.  des  Hop.,  1905  ;  Digne, 

La  cure  de  dechlorination  chez  les  cardiaques,  These 
(Paris,  1905) ;  Bayer,  Arch.f.  exp.  Path.  u.  Pharm., 
1907,  vol.  Ivii.,  p.  162  et  seq.;  G.  Etienne,  Archiv  d. 
Maladies  des  Cceur,  1908,  vol.  i.,  p.  129. 


LITERATURE  OF  Off  AFTER  X          265 

13  Halliburton,  in  Schafer's  Handbook  of  Physiol.,  1898, 

vol.  i.,  p.  130. 

14  Meilach,  These  de  Paris,  1889,  quoted  in  Meyer  and 

Gottlieb's  Experiment.  Pharmacologie,  p.  299. 

15  Goulston,  Brit.  Med.  Journ.,  1911,  vol.  i.,  p.  615. 

10  A.  H.  Carter,  Brit.  Med.  Journ.,  1911,  vol.  ii.,  p   1401. 

17  Winternitz.   (Demonstration  which  I  sawinhrs  Klinik.) 

18  Lauder   Brunton,    1882,    The  Practitioner,  vol.    xxix., 

p.  280. 

19  Lauder  Brunton,  "On  Cardiac  Diseases,"  1897,  Edin. 

Med.  Journ.,  vol.  ii.,  p.  446. 

20  Lauder   Brunton,    Clinical    Society  Reports,   vol.    iii., 

1870  ;  and  Collected  Papers,  First  Series,  p.  186. 

21  Lauder  Brunton,  St  Bartholomew's  Hospital  Reports^ 

1875,  vol.  xi.,  p.  167  et  seq. 

22  Herbert  Davies,  Lancet,  1865,  vol.  ii.,  pp    127,  213, 

and  248. 


CHAPTER   XI 

ACTION   OF  CARDIAC    AND    VASCULAR 
REMEDIES 

Action  of  Drugs  on  the  Circulation — Its  Complexity — 
Means  of  Examining  the  Different  Factors  — 
Investigation  of  the  Action  of  Drugs  on  the 
Frog's  Heart  —  Different  Reactions  of  the 
Inside  and  Outside  of  the  Frog's  Ventricle  — 
Artificial  Circulation  through  Mammalian  Vessels  ; 
through  the  Mammalian  Heart  —  Examination  of 
the  Effects  of  Poisons  on  the  Heart  and  Vessels  in 
the  Body — General  Rules  regarding  the  Action  of 
Drugs — Selective  Action — Peripheral  and  Central 
Action — Effect  of  Dosage — Varying  Composition 
of  Drugs —Condition  of  the  Body — Inurement — 
Temperature — Season — Climate — Necessity  for  Care 
in  drawing  Conclusions^ — Classification  of  Cardiac 
and  Vascular  Remedies — Cardiac  Nutrients — Effect 
of  Inorganic  Salts  on  the  Heart — Albuminous  Sub- 
stances—  Sugars  —  Purin  Bodies,  Caffeine,  etc. — 
Cardiac  Tonics — Cause  of  Normal  Tone. 

Action  of  Drugs  on  the  Circulation. — Diseases 
of  the  heart  and  circulation  are  capable  of  being 
benefited  to  an  enormous  extent  by  the  proper 
use  of  drugs,  but  in  order  that  these  should  do 
good  only,  and  do  no  harm,  a  fairly  exact  know- 
ledge of  their  mode  of  action  is  needful.  But 
this  is  very  difficult  indeed  to  obtain,  because 

266 


ACTION  OF  DRUGS  ON  FROG'S  HEART  267 

the  action  of  drugs  upon  the  circulation  is 
exceedingly  complex.  What  makes  it  all  the 
more  difficult  is  that  pharmacology  has  outrun 
physiology  so  much  that  the  action  of  drugs  is 
now  used  to  aid  in  the  solution  of  some  of  the 
most  difficult  physiological  questions.  For 
example,  it  is  impossible  to  ascertain  by 
ordinary  physiological  methods  whether  the 
vagus  contains  accelerating  as  well  as  inhibitory 
fibres.  When  the  vagus  trunk  is  irritated,  slow- 
ing or  stoppage  of  the  heart  almost  always  occurs, 
and  not  acceleration.  This  result  might  be  due 
to  the  absence  of  accelerating  fibres,  or  to  their 
action  being  masked  by  the  superior  power  of 
accompanying  inhibitory  fibres.1  By  the  use  of 
atropine,  however,  the  question  of  the  presence 
of  accelerating  fibres  along  with  the  inhibitory 
has  been  completely  settled,  for  this  drug 
paralyses  the  peripheral  terminations  of  the 
inhibitory  fibres,  and  after  its  administration 
stimulation  of  the  vagus  trunk  not  only  pro- 
duces no  slowing  whatever,  but  actual  accelera- 
tion. So  complex  is  the  action  of  drugs  on  the 
circulation,  that  it  would  have  been  impossible 
to  ascertain  the  action  of  each  on  the  heart  and 
vessels  separately,  without  the  method,  invented 
by  Carl  Ludwig,  of  artificial  circulation. 

Investigation  of  the  Action  of  Drugs  on  the 
Prog's  Heart. — In  the  winter  of  1869,  when 
H.  P.  Bowditch  and  I  were  both  working  in 
Ludwig's  laboratory,  I  adapted  the  apparatus 
which  he  was  using  for  the  physiology  of  the 
frog's  heart z  to  the  examination  of  poisons  upon 
it,  by  adding  two  small  Marriott's  vessels,  one  of 


268    CARDIAC  AND  VASCULAR  REMEDIES 

which,  K,  contained  pure  nutrient  solution  and 
the  other,  K',  poisoned  solution  (Fig.  86).  The 
whole  apparatus  consisted  of  those  two  receivers, 
which  fed  a  bent  tube,  BB',  having  cannulae 


Fio.  86. — Apparatus  for  examining  the  action  of  drugs  on  the  frog's  heart. 
A  is  the  heart  With  one  cannula,  B,  tied  into  the  vena  cava,  and 
another,  B',  into  the  aorta.  The  nutrient  fluid  is  driven  from  the 
aorta  through  the  bent  tube  C  into  the  vena  cava,  whence  it  passes  on 
again  through  the  heart.  The  beats  are  recorded  by  the  manometer 
M  on  the  recording  cylinder  Q.  K  and  K'  are  two  Marriott's  bottles, 
one  containing  nutrient  fluid  pure  and  the  otliT  poisoned.  Either 
can  be  supplied  to  the  heart  at  will  through  the  tubes  J  and  H  con- 
necting  them  with  C. 

attached  to  both  ends.  One  of  these,  B,  was 
inserted  into  the  vena  cava  and  the  other,  B', 
into  the  aorta  of  a  frog's  heart,  so  that  the  fluid 
passed  round  the  tube  in  an  artificial  circulation. 
To  one  side  of  this  tube  was  attached  a  small 


REACTIONS  OF  FROG'S  VENTRICLE    269 

manometer,  M,  which  recorded  the  movements 
of  the  heart  on  a  revolving  cylinder,  Q.  This 
apparatus  I  described  and  figured  in  the  British 
Medical  Journal  in  i8/i.3  In  this  apparatus  the 
whole  frog's  heart  was  examined.  A  more 
elaborate  one  for  examining  the  action  of  drugs 
on  the  frog's  ventricle  alone  was  described  by 
Professor  Kronecker  in  1874,*  and  shown  by 
him  at  The  International  Exhibition  of  Scien- 
tific Apparatus  in  London  in  i8/6.5  The 
apparatus  was  still  further  improved  by 
Williams,  who  introduced  valves  allowing  the 
fluid  to  circulate  only  in  one  direction.6 

Different  Reactions  of  the  Outside  and  Inside 
of  the  Prog's  Ventricle. — Mechanical  stimula- 
tion of  the  outside  of  the  frog's  ventricle  may  be 
without  effect,  while  stimulation  of  its  inside 
may  cause  one  contraction  of  the  ventricle  and 
three  or  four  of  the  auricle.  This  shows  a 
difference  in  sensibility  between  the  two  sur- 
faces, and  might  be  regarded  as  indicating  the 
presence  of  reflex  nervous  centres  in  the  heart 
which  reacted  differently  to  stimuli  from  these 
points. 

There  is  also  a  difference  in  the  action  of  the 
heart  to  poisons  applied  to  the  outside  and  inside 
of  the  ventricle.  Thus  strychnine  applied  to  the 
outside  of  the  frog's  ventricle  does  not  induce 
pulsation  when  its  movements  have  been  stopped 
by  a  ligature  round  the  auriculo-ventricular 
groove.  But  if  it  is  injected  into  the  interior 
of  the  ventricle,  it  causes  the  pulsations  to  re- 
commence ;  and  if  injected  into  the  lymph  sac  so 
as  to  circulate  in  the  blood  before  the  ligature 


270    CARDIAC  AND  VASCULAR  REMEDIES 

is  applied,  it  prevents  the  stoppage  which  would 
otherwise  occur.* 

It  has  been  found  by  Schmiedebergf  and 
others  that  most  cardiac  poisons,  digitalin  and 
other  members  of  the  group,  strophanthin,  scil- 
lain,  convallamarin,  helleborein,  bufotalin,  and 
barium  chloride,  when  applied  to  the  outside  of 
the  ventricle  cause  standstill  in  diastole,  which 
only  passes  into  systole  after  sufficient  time  has 
elapsed  for  them  to  soak  through  the  ventricle 
and  reach  its  interior.  But  when  injected  into 
the  interior  of  the  heart  or  when  they  reach  it 
through  the  general  circulation,  they  at  once 
cause  increased  systolic  contraction  and  stand- 
still in  systole. 

This  curious  result  is  explained  by  Schmie- 
deberg  on  the  hypothesis  that  there  are  two 
kinds  of  muscular  fibres  in  the  frog's  heart,  one 
set  contracting  it  (systolic  fibres)  and  a  second 
dilating  it  (diastolic  fibres).  The  systolic  fibres, 
he  thinks,  are  innervated  by  the  accelerator 
nerves,  but  are  influenced  by  substances  of  the 
digitalis  group  in  such  a  way  that  they  contract 
more  strongly  and  tend  to  remain  contracted. 

It  seems  to  me  that  instead  of  ascribing  this 
result  to  the  presence  of  two  antagonistic  sets 
of  muscular  fibres,  it  might  be  more  easily 
explained  on  the  assumption  that  the  muscu- 
lar cells  of  the  heart  contract  transversely  as 
well  as  longitudinally  (p.  86).  If  the  power  of 
muscular  fibres  or  cells  to  contract  transversely 
be  assumed,  it  would  serve,  I  think,  to  explain 

*  Brunton    and    Cash,    St   Bartholomew's    Hospital 
Reports,  1880,  vol.  xvi ,  p.  230. 

t  Schmiedeberg,  Grund.  d.  Pharmakol,,  pp.  228-9. 


PERFUSION  OP  MAMMALIAN  VESSELS  271 

not  only  active  dilatation  of  capillaries,  arteries, 
and  veins,  but  of  the  heart.  The  refractory  period 
in  the  heart  might  be  also  regarded  as  being 
one  in  which  stimulation  tended  to  cause  trans- 
verse contraction  of  the  cells. 

Apparatus     for    Artificial     Circulation    in 
Mammalian  Vessels. — In  the  summer  of  1869 


FIG.  87.—  Apparatus  for  examining  the  effect  of  poisoned  and  unpoisoned 
blood  in  the  rabbit's  ear.  This  consists  of  two  bottles,  B  and  E',  one 
of  which  contains  pure  and  ihe  other  poisoned  blood.  This  is  kept 
at  blood-heat  by  the  bottles  being  immersed  in  water  in  a  tin  vessel,  G, 
heated  by  a  gas-burner,  J,  with  a  regulator,  L  (shown  also  at  W). 
The  blood  is  passed  from  the  tabes  M  into  the  carotid  of  a  rabbit's 
severed  head,  which  is  also  kept  warm  by  the  water-jacket.  The 
pressure  can  be  adjusted  as  desired  by  raising  or  lowering  the  bottle 
which  contains  mercury. 

I  examined,  under  the  direction  of  Professor 
Ludwig,  the  contraction  of  arterioles  throughout 
the  body  independently  of  the  central  nervous 
system.7  In  the  winter  of  the  same  year  he 
wished  me  to  continue  these  researches,  using 
artificial  circulation  of  pure  blood  and  poisoned 
blood  to  ascertain  the  effect  of  drugs  upon  the 
vessels.  This  apparatus  I  described,  in  1871, 
in  the  British  Medical  Journal t  and  also  Ludwig's 


272    CARDIAC  AND  VASCULAR  REMEDIES 

method  of  keeping  up  artificial  circulation  in 
frogs  or  mammals.  These  papers  I  afterwards 
republished  in  the  form  of  a  small  book,  which 
was,  I  believe,  the  first  textbook  of  experimental 
pharmacology  (Experimental  Investigations  of  the 
A  ction  of  Medicines,  1875.  London:  Churchill).8 
Unfortunately  I  was  prevented  from  carrying 
out  the  research,  but  it  was  continued  by  Mosso 
on  other  organs,9  as  Ludwig  had  reserved  the 
rabbit's  ear  for  investigation  by  me  if  ever  I 
should  be  able  to  resume  it. 

Artificial  Circulation  through  the  Mam- 
malian Heart. — As  early  as  1846  Ludwig  had 
kept  a  mammalian  heart  alive,10  apart  from  the 
body,  by  supplying  it  with  blood  from  the 
carotid  of  another  animal;  but,  so  far  as  I  know, 
this  method  was  not  further  developed,  either 
by  himself  or  his  pupils  at  Leipzig.  It  was 
again  taken  up  by  H.  N.  Martin11  in  1881-1882, 
and  has  been  utilised  to  a  large  extent  by 
Langendorff.12  By  this  method  the  descending 
aorta  and  subclavians  are  ligatured  and  all  the 
veins  excepting  one  jugular.  Into  one  carotid 
a  manometer  is  tied,  and  into  the  other  a  tube 
which  connects  that  carotid  with  the  jugular 
vein  and  represents  the  entire  systemic  circula- 
tion, as  there  is  no  other  communication  between 
the  aorta  and  the  right  side  of  the  heart.  The 
blood  then  flows  through  the  carotid  and  the 
jugular  veins  into  the  right  heart,  and  is  driven 
by  the  pulmonary  arteiy  into  the  lungs,  which 
are  kept  in  action  by  artificial  respiration.  By 
this  apparatus  the  pressure  in  the  aorta  can  be 
registered  for  hours  together,  and  the  heart 


RULES  REGARDING  ACTION  OF  DRUGS  273 

subjected  to  the  action  of  any  drug  which  it  is 
wished  to  investigate.  As  a  nutrient  fluid 
defibrinated  blood,  alone  or  diluted  with  normal 
saline,  may  be  used ;  but  it  is  generally  found 
more  convenient  to  employ  Ringer's  fluid  as 
modified  by  Locke  and  fully  aerated  by  means 
of  oxygen.13 

General  Rules  regarding  the  Action  of 
Drugs. — In  trying  to  form  a  precise  idea  of  the 
action  of  drugs  upon  the  heart  and  vessels  it  is 
important  to  bear  the  following  general  rules  in 
mind  : — 

(1)  That — Drugs   have  a  selective  action   on 
particular  structures  or  tissues. 

(2)  That — Their  action  may  be  peripheral,  or 
central,  or   both,   and   these   two   actions   may 
either  aid  one  another  or  counteract  each  other. 

(3)  That — Their  action  may  be  modified  by 
the  dose,  and  that  large  doses  have  sometimes 
exactly  the  opposite  effect  of  small  ones,  small 
ones  stimulating  and  large  ones  paralysing. 

(4)  That — The  drug  itself,  which  is  supposed 
to  be  simple,  may  really  be  compound,  and  may 
contain  components  having  actions  antagonistic 
to  each  other. 

(5)  That — The   action  of  the   drug  may  be 
aided  or  interfered  with  by  the  chemical  com- 
position of  the  blood  and  tissues  at  the  time  of 
its  administration. 

(6)  That — It  may  be  interfered  with  by  the 
cells   or    tissues   of  the    body   having  become 
inured  to  the  action  of  the  drug. 

(7)  That — It  may  be  interfered  with  by  the 
temperature  of  the  body. 


274    CARDIAC  AND  VASCULAR  REMEDIES 

It  may  be  well  now  to  take  these  rules  one 
by  one  and  consider  them  more  fully. 

(i)  Selective  Action. —  The  fact  that  drugs 
have  a  selective  action  on  particular  structures 
or  tissues  is  well  known  to  everyone  who  does 
microscopical  work,  for  it  is  by  means  of  the 
selective  action  of  tissues  for  different  stains 
that  a  great  deal  of  our  histological  knowledge 
has  been  gained.  It  often  happens  that  many 
tissues  have  an  affinity  for  the  same  stain,  but 
not  to  the  same  degree,  so  that  if  it  is  applied 
for  a  short  time  only,  one  tissue  becomes  stained, 
if  for  a  longer  time  a  second  takes  it  up,  and  if 
for  a  longer  time  still,  a  third,  and  so  on. 
Frequently  the  stain  can  be  washed  away  from 
the  tissues  in  inverse  order.  The  same  thing 
that  can  be  seen  with  stains  happens  also  with 
alkaloids  and  other  drugs,  where  the  effect  is 
not  visible  to  the  eye,  but  can  be  discovered 
by  other  means.14  Thus  atropine  has  a  pecul- 
iar affinity  for  the  peripheral  terminations  of 
cerebro  -  spinal  nerves  going  to  involuntary 
muscles  or  glands,  and  in  comparatively  small 
doses  it  will  paralyse  them.  The  vagus  belongs 
to  this  class  of  nerves,  and  its  inhibitory  fibres 
are  paralysed  by  small  doses.  It  paralyses 
other  nerves  of  this  class,  and  through  its  action 
on  the  third  nerve  it  causes  dilatation  of  the 
pupil ;  through  the  chorda  tympani  it  causes 
dryness  of  the  mouth,  and  these  actions  may 
even  precede  its  effect  upon  the  pulse.  But 
when  pushed  still  further  it  acts  on  the  nerve 
centres,  producing  first  excitement,  and  after- 
wards paralysis.15  In  mammals  this  action 


SELECTIVE  ACTION  OP  DRUGS        275 

usually  causes  death  before  the  drug  can  act 
much  upon  the  ends  of  motor  nerves  in 
voluntary  muscle.  This  action  may,  however, 
be  made  out  by  the  local  application  of  the 
poisons  to  the  muscle  of  a  frog.  Another 
poison,  curare,  has  somewhat  similar  actions, 
but  in  an  inverse  order,  for  while  comparatively 
small  doses  of  it  paralyse  the  ends  of  motor 
nerves  in  voluntary  muscles,  much  larger  doses 
are  required  to  paralyse  the  vagus.16  Nicotine 
appears  to  have  a  peculiar  affinity  for 
sympathetic  ganglia,  and  to  exercise  on  them  a 
paralysing  action ;  so  that  if  a  cerebro-spinal 
nerve  ending  in  one  of  those  ganglia  is  irritated 
between  the  ganglion  and  the  spine  (pre- 
ganglionic  fibre),  no  effect  is  produced ;  but  if 
the  nerve  passing  from  the  ganglion  to  an 
organ  (post-ganglionic  fibre)  is  stimulated,  it 
produces  this  effect  as  well  after  as  before  the 
poison.17  The  mode  in  which  selective  drugs  act 
on  nerves  has  been  recently  discussed  by  Dixon.18 
An  affinity  of  alcohol  for  the  brain  was  recog- 
nised by  Dr  Percy  in  i839,19  as  he  found  a 
much  larger  proportion  in  animals  poisoned  by 
it  in  the  brain  than  in  other  organs.  His 
observation  regarding  such  an  affinity  has 
been  confirmed  and  extended  to  other  members 
of  the  aliphatic  series.20  Hans  Meyer,  in  i899,21 
propounded  the  theory  that  substances  which, 
like  most  of  this  series,  are  soluble  in  fats,  or 
fatty  bodies  (lipoids),  must  act  on  cells  con- 
taining them,  and  especially  on  nerve  cells,  and 
thus  exercise  a  narcotic  action.  This  has 
been  confirmed  by  Overton  and  others. 


276    CARDIAC  AND  VASCULAR  REMEDIES 

(2)  Peripheral  and  Central  Action.  —  The 
second  rule  is  that  the  action  of  drugs  may  be 
peripheral,  or  central,  or  both.  Indeed  in  most 
cases  it  is  both,  though  in  different  degrees,  as 
1  have  already  mentioned.  One  can  readily 
understand  why  it  should  be  so,  because  both 
nerve  centres  and  peripheral  nerves  contain 
substances  of  a  more  or  less  fatty  nature 
(lipoid),  and  for  such  substances  many  alkaloids, 
as  well  as  alcoholic  and  ethereal  substances, 
have  a  special  affinity.22 

Central  and  peripheral  actions  may  aid  one 
another,  as  in  the  case  of  amyl  nitrite,  which  has 
a  dilating  effect  upon  the  vessels  both  by  its 
action  upon  the  nerve  centres  and  upon  the 
peripheral  vessels  themselves.23 

On  the  other  hand,  the  central  and  peripheral 
actions  of  a  drug  may  oppose  one  another.  Thus 
adrenalin  stimulates  the  accelerating  centres  in 
the  heart  itself  and  thus  tends  to  quicken  the 
pulse.  At  the  same  time,  by  its  peripheral 
action  on  the  vessels  it  causes  them  to  contract 
and  produces  a  great  rise  of  blood-pressure. 
This  stimulates  the  inhibitory  centre  of  the 
vagus  and  tends  to  slow  the  pulse.  The  rate  of  the 
pulse  is  therefore  determined  by  the  extent  to 
which  one  or  other  of  these  factors  prevails,  and 
generally  the  pulse  is  first  slow  and  then  quick. 

Caffeine  stimulates  the  vaso- motor  centre 
and  thus  tends  to  make  the  arterioles  contract, 
but  by  its  local  action  on  the  vessels  themselves 
it  tends  to  produce  dilatation,  and  here  again  the 
blood-pressure  will  depend  upon  the  balance 
between  these  two  conditions.24 


DOSAGE-VARYING  COMPOSITION      277 

(3)  Effect  of  Dosage. — The  third  rule  is  that 
the  action  may  be  modified  by  the  dose,  and 
large  doses   may  sometimes   have  exactly  the 
opposite  effect  of  small  ones.     This  is  very  well 
marked  in  the  case  of  nicotine.     Small   doses 
stimulate  the  ends  of  the  vagus  in  the   heart 
and   greatly  slow  the  pulse,  while   larger  ones 
completely  paralyse  these  structures  and  make 
the  pulse  very  quick.     The  same  opposite  effect 
of  large  and  small  doses  is  seen  in  the  case  of 
digitalis,  although  the  modus  operandi  may  be 
slightly  different,  for  small  doses  slow  the  heart 
by  stimulating  the  vagus  roots,  while  large  doses 
remove  the  inhibitory  action  of  the  vagus  in  the 
heart  itself  and  thus  render  the  pulse  quick.25 

Even  atropine,  which  in  very  minute  doses 
paralyses  the  ends  of  the  vagus  in  the  heart  and 
renders  the  pulse  quick,  appears  to  have  the 
opposite  action  when  the  dose  is  exceedingly 
minute,  and  slows  the  heart  instead  of  quicken- 
ing it.  So  minute  is  the  dose  required,  however, 
that  this  action  has  been  missed  by  many 
observers  and  its  existence  denied.26  Opium 
as  a  rule  tends  to  constipate ;  but  when  a  large 
dose  is  injected  directly  into  a  vein  in  a  dog,  it 
produces  most  violent  intestinal  peristalsis,  so 
that  the  faeces  are  evacuated  so  suddenly  and 
in  such  quantity  that,  before  laudanum  was  in- 
jected into  the  vein  for  the  purpose  of  producing 
narcosis  before  an  experiment  in  Ludwig's 
laboratory,  a  quantity  of  tow  was  placed  at  the 
anus  of  the  animal  in  order  to  receive  the 
excrement. 

(4)  Varying  Composition  of  Drugs. — A  drug 


278    CARDIAC  AND  VASCULAR  REMEDIES 

which  is  supposed  to  be  simple  may  really  be 
compound  and  may  contain  components  having 
antagonistic  actions.  This,  of  course,  is  well 
known  in  regard  to  crude  drugs  such  as  opium, 
which  contains  many  alkaloids,  one  of  which, 
morphine,  is  purely  soporific,  while  another, 
thebaine,  has  almost  no  soporific  action,  but  is 
a  pure  convulsant  like  strychnine.27  The  same 
thing  occurs  in  what  is  sometimes  regarded  as 
pure  active  principles.  Thus  muscarine,  the 
active  principle  of  the  fly-fungus,  has  the 
remarkable  power  of  stimulating  the  inhibitory 
apparatus  in  the  heart  and  causing  it  to  stand 
still  in  complete  diastole.28  This  action  is 
antagonised  in  the  most  complete  manner  by 
atropine.29  But  all  specimens  of  muscarine  are 
not  equally  pure,  and  most  of  them  contain 
more  or  less  of  another  substance,  which  has  an 
action  just  like  atropine  and  antagonises  mus- 
carine.29 The  action  of  any  specimen  of  mus- 
carine will  therefore  depend  upon  its  more  or 
less  complete  freedom  from  admixture  with  this 
other  alkaloid.30 

Digitalis  itself  probably  contains  at  least  four 
different  principles  which  have  an  action  some- 
what alike  but  not  identical,  and  the  same  is 
probably  true  of  nearly  all  the  substances 
belonging  to  the  digitalis  group.31 

(5)  Condition  of  Body. — The  action  of  a  drug 
may  be  aided  or  interfered  with  by  the  chemical 
composition  of  the  blood  and  tissues  at  the  time 
of  its  administration. 

Thus  Cash  and  I  found  that  the  poisonous 
effect  of  barium  is  not  only  counteracted  to 


CONDITION  OF  BODY— INUREMENT   279 

some  extent  by  potash  administered  at  the 
same  time,  but  by  administration  of  potash  for 
some  days  previously.32  We  found  that  beef 
tea  counteracts  the  effect  of  barium  on  a  frog's 
muscle;33  but  we  made  no  experiments  on  its 
power  to  do  so  in  the  body.  Hans  Meyer 
found  that  the  withdrawal  of  normal  calcium 


Fio.  83. 

I.  Curve  of  gastrocnemius  in  a  frog  in  its  normal  condition. 
II.  Curve  of  the  same  muscle  after  immersion  for  20'  in  barium  chloride 

solution  1-500. 

III.  Curve  of  the  same  muscle  after  immersion  for  2CC  in  dilated  Liebig's 
extract  1-800. 

salts   produces   hyper-excitability   of  the  sym- 
pathetic system  towards  adrenalin.34 

(6)  Inurement. — The  action  of  a  drug  may  be 
interfered  with  by  the  cells  or  tissues  of  the 
body  having  become  inured  to  it.  A  well- 
known  example  of  this  is  morphine,  which  in 
many  persons  when  taken  for  a  length  of  time 


280    CARDIAC  AND  VASCULAR  REMEDIES 

greatly  loses  its  effect,  so  that  the  dose  has  to  be 
constantly  increased  in  order  to  obtain  its  usual 
effects.  In  this  respect  the  effect  of  muscarihe 
on  the  frog's  heart  is  very  extraordinary.  If 
the  heart  be  perfused  with  a  solution  containing 
muscarine  it  stops  a  long  time  in  complete 
diastole.  After  some  time  it  again  begins  to 
beat.  If  more  muscarine  is  again  added  the 
same  thing  happens  again,  and  this  may  be 
repeated  several  times.  The  apparent  cessa- 
tion of  the  action  upon  the  heart  is  not  due  to 
the  muscarine  having  been  destroyed.  For  if 
the  heart  be  taken  after  it  has  just  begun  to 
beat  again  for  the  first  time,  and  the  fluid  it 
contains  is  washed  out,  enough  muscarine  may 
still  be  separated  from  the  heart  itself  to  pro- 
duce its  characteristic  action  upon  another  heart. 
It  is  thus  clear  that  the  action  is  not  determined 
by  the  actual  amount  of  poison  present,  but  by 
its  distribution.35  This  phenomenon  becomes 
readily  intelligible  by  the  consideration  of 
Ehrlich's  schema  of  a  cell.  In  the  centre  of  a 
cell  is  protoplasm  in  a  completely  reduced  state, 
at  the  periphery  in  a  completely  oxidised  state, 
and  between  these  two  is  a  layer  alternately 
more  or  less  oxidised  or  reduced.  The  function 
of  the  cell  depends  upon  the  relative  oxidation 
or  reduction  of  its  different  layers.36  If  we 
suppose  that  the  same  occurs  with  poisons 
present  in  it  we  can  readily  see  that  as  the 
poison  becomes  uniformly  distributed  through 
the  cell  its  effect  may  cease,  and  that  only  the 
different  proportion  present  in  the  outer  layer  or 
protoplasm  will  produce  the  effect. 


TEMPERATURE  281 

(7)  Temperature. — The  action  of  drugs  may 
be  interfered  with  by  the  temperature  of  the 
body.  Perhaps  one  of  the  most  marked 
examples  of  this  is  digitalis,  which  at  a  high 
temperature  completely  loses  its  power  of 
slowing  the  heart  through  the  vagus.37  Neglect 
of  the  temperature  at  which  experiments  have 


FIG.  89.— The  lowest  muscle  curve  is  taken  from  a  veratria  muscle 
cooled  to  15°  C.  The  middle  curve  is  taken  from  the  same  muscle  at 
room  temperature ;  the  uppermost  curves  from  the  same  muscle  heated 
to  25°  C.  (Brunton  and  Cash.) 

been  made  is  one  cause  of  the  contradictory 
results  which  have  frequently  been  obtained 
in  the  investigation  of  the  action  of  different 
drugs.  Thus  atropine  was  found  by  Bowditch 
and  Luciani  to  increase  the  systolic  contraction 
of  the  frog's  heart;38  while  Gnauck,39  on  the 
other  hand,  obtained  an  exactly  opposite  result, 

U 


262    CARDIAC  AND  VASCULAR  REMEDIES 

and  found  that  both  atropine  and  hyoscya- 
mine  diminished  ventricular  contraction.  At 
Kronecker's  suggestion,  the  research  was  taken 
up  anew  by  Schapiro,40  who  repeated  the 
experiments  at  different  temperatures,  and 
found  that  both  observers  were  right,  and 
both  were  wrong.  When  the  experiments 
were  made  at  a  low  temperature,  7°  to  8°  C., 
atropine  amplified  the  contractions  of  the 
heart,  as  stated  by  Bowditch  and  Luciani; 
but  when  the  temperature  rose  about  15°  C., 
atropine  had  an  exactly  opposite  effect,  and 
diminished  the  contractions,  as  stated  by 
Gnauck. 

Veratrine  when  applied  to  a  frog's  muscle 
at  ordinary  temperatures  produces  an  extra- 
ordinary prolongation  of  the  contraction,  but 
this  characteristic  action  is  removed  by  heat 
or  by  cold.41 

Effect  of  Season. — The  effect  of  seasons  of 
the  year  upon  the  antagonistic  action  of  drugs 
in  the  body  was  observed  by  Luciani42  and 
also  by  Ringer,43  who  found  that  while  pilo- 
carpine  antagonises  the  action  of  muscarine, 
and  atropine  antagonises  aconitine  upon  frogs 
in  summer,  it  has  no  such  action  in  winter. 

Similar  observations  were  made  by  Pantelejeff 
in  regard  to  atropine  and  quinine.44  In 
summer,  quinine  arrests  the  frog's  heart  in 
diastole;  atropine  subsequently  administered 
causes  the  pulsations  of  the  heart  to  recom- 
mence. In  winter,  quinine  acts  much  more 
slowly  upon  the  heart,  and  atropine  increases 
instead  of  antagonising  its  action. 


SEASON— CLIMATE  283 

Climate.—  The  opinion  expressed  by  various 
authors,  that  the  action  of  drugs  may  be  largely 
varied  by  climate,  has  often  been  received  with 
distrust.  There  seemed  to  be  no  very  definite 
reason  for  supposing  that  climate  should 
exercise  this  action,  and  so  any  difference 
that  might  exist  was  apt  to  be  ascribed  to 
other  causes.  The  statement  of  Lisfranc, 
that  the  inhabitants  of  southern  climates 
tolerate  much  larger  doses  of  barium  than 
those  of  northern  climates,  is  at  first  sight 
curious,  and  one  may  be  inclined  to  be 
sceptical  regarding  it.  There  seems  no 
obvious  reason  why  an  inorganic  substance 
like  barium  should  act  differently  in  Italy 
and  in  England,  although  one  might  be 
inclined  to  grant  that  such  a  modification 
might  perhaps  occur  in  the  case  of  more 
complex  and  less  stable  organic  substances. 
The  marked  effect  of  heat  upon  voluntary 
muscle  poisoned  by  veratrine,  however,  seems 
to  indicate  that  the  resistance  opposed  to  the 
action  of  the  drug  by  inhabitants  of  warmer 
countries  may  be  due  to  the  higher  tempera- 
ture, and  Cash  and  I  have  found  experimentally 
that  cold  retards  the  fatal  effect  of  barium  upon 
guinea-pigs.45 

Necessity  for  Care  in  drawing  General 
Conclusions. — Contradictory  statements  regard- 
ing the  action  of  drugs  have  sometimes  been 
due  to  different  observers  employing  animals 
of  different  kinds  or  of  different  species  in 
their  experiments,  and  concluding  that  the 
results  they  obtained  were  applicable  to  all 


284    CARDIAC  AND  VASCULAR  REMEDIES 

animals.  Thus  Johannsen46  found  that  caffeine 
caused  rigidity  in  the  muscles  of  frogs.  Aubert 47 
found  that  it  did  not.  This  difference  of  result, 
according  to  Schmiedeberg,48  was  due  to  the 
employment  of  Rana  temporaria  by  Johannsen 
and  of  Rana  esculenta  by  Aubert.  Morphine 
acts  as  a  narcotic  in  most  animals,  but  on 
pigeons  it  acts  as  an  antipyretic.49 

Classification  of  Cardiac  and  Vascular 
Remedies. — These  may  be  divided  into  six 
classes : — 

1.  Cardiac  nutrients. 

2.  Cardiac  tonics. 

3.  Cardiac  stimulants. 

4.  Cardiac  depressants. 

5.  Vascular  contractors. 

6.  Vascular  dilators. 

In  addition  to  these  we  have  a  number  of 
drugs  which  have  a  less  direct  action  upon  the 
heart  and  vessels  themselves,  but  rather  affect 
tissue  change  and  the  composition  of  the  blood, 
and  influence  the  heart  indirectly  through  other 
organs.  Thus  digestives,  and  eliminants  both  by 
the  bowels  and  kidneys, are  important  adjuncts  to 
the  drugs  which  act  directly  upon  the  circulation. 

Cardiac  Nutrients. — The  best  nutrient  for 
the  heart  is,  of  course,  well  aerated  blood,  with  a 
proper  proportion  of  nutrient  matter  and  few 
waste  products.  The  action  of  nutrient 
materials  has  been  investigated  by  experiments 
both  upon  the  frog's  heart  and  upon  the  mam- 
malian heart  by  methods  which  we  owe  to  Carl 
Ludwig.  In  the  first  experiments  made  by  him 
and  his  pupils  on  the  frog's  heart,  serum  was 


CARDIAC  NUTRIENTS  285 

used,  and  later  a  simple  solution  of  common  salt 
(NaCl)  about  -5  to  -6  per  cent.,50  that  is  to  say 
about  two  and  a  half  grains  to  the  ounce,  was 
circulated  artificially  through  the  frog's  heart. 
For  a  length  of  time  it  continued  to  beat,  but 
gradually  the  pulse  became  slower  and 
feebler  and  at  last  ceased.  The  addition  of 
diluted  blood  increased  the  strength  and  made 
it  beat  for  a  longer  time,51  and  when  it  stopped, 
the  stoppage  was  not  due  to  exhaustion  of  the 
nutrient  material  but  to  accumulation  of  waste 
products,  so  that  when  these  were  washed  out 
with  saline  solution  containing  a  very  small 
quantity  of  sodium  carbonate,  the  heart  began 
to  beat  again.52 

Effect  of  Inorganic  Salts  upon  the  Heart. — 
An  interesting  and  important  discovery  was 
made  by  Ringer,  who  found  that  when  the 
saline  solution  was  made  with  tap-water  it 
maintained  the  action  of  the  heart  for  a  very 
much  longer  time  than  when  made  with  distilled 
water.53  On  investigating  the  cause  of  this,  he 
found  it  was  the  lime  in  the  tap-water  which 
had  a  stimulating  effect  upon  the  heart,  and  he 
was  able  to  produce  nearly  the  same  effect  by 
adding  lime  in  imall  quantities  to  saline  solu- 
tion made  with  distilled  water.54  But  if  the 
heart  be  perfused  with  saline  and  calcium  alone 
the  diastole  tends  to  become  less  and  less,  and 
finally  the  heart  stands  still  in  a  condition  of 
systole.55  If  a  small  quantity  of  potassium  be 
added  to  this  solution  the  diastole  becomes 
more  complete  and  the  heart  goes  on  acting  in 
a  very  perfect  manner.  If  the  proportion  of 


286    CARDIAC  AND  VASCULAR  REMEDIES 

potassium,  however,  be  too  large,  the  diastole 
becomes  greater  and  greater,  and  finally  the 
heart  stands  still  in  complete  diastole.56  To 
maintain  rhythmical  contraction,  a  proper 
proportion  is  required  between  the  salts  of  Na, 
K  and  Ca  in  the  nutrient  fluid.57  There  seems 
to  be  a  close  relationship  between  the  presence 
of  potassium  in  the  nutrient  fluid  and  the  action 
of  the  vagus.  Excess  of  potassium  and  stimula- 
tion of  the  vagus  both  cause  the  heart  to  stop  in 
diastole.  If  the  potassium  be  thoroughly  washed 
out  of  the  heart  by  means  of  normal  saline,  the 
vagus  loses  its  inhibitory  power,  and  if  the 
amount  of  potassium  in  the  perfused  fluid 
entering  and  leaving  the  heart  be  estimated 
during  vagus  irritation  it  is  found  that  the 
quantity  leaving  the  heart  is  increased,  the 
stimulation  of  the  nerve  having  apparently 
caused  such  dissociation  as  to  free  the  potassium 
and  to  allow  of  its  removal.  It  is  not  improb- 
able that  the  whole  question  of  the  mode  of 
action  of  the  vagus,  and  of  the  transmission  of 
stimuli  through  the  A-V  bundle  may  finally 
turn  out  to  be  a  chemical  one.68 

Albuminous  Substances. — It  has  been  shown 
by  Kronecker 59  that  although  a  heart  supplied 
with  salts  alone  may  continue  beating  for  a 
length  of  time,  yet  it  becomes  much  more 
quickly  exhausted  than  if  albuminous  substances 
of  the  proper  character  are  supplied  to  it. 

It  is  not  every  kind  of  albuminous  substance 
which  will  act  as  a  nutrient.  Serum  albumen 
does  so,  but  neither  egg  albumen,  casein  of 
milk,  syntonin,  nor  peptone  act  as  nutrients.00 


ALBUMINS— SUGARS— PURINS          287 

Sugars. — Amongst  the  most  powerful  cardiac 
nutrients  appears  to  be  glucose ;  for  Locke 
found  in  his  experiments  that  the  addition  of 
glucose,  even  in  very  small  quantity,  to  a  saline 
fluid  greatly  increased  its  nutritive  effect  on  the 
isolated  mammalian  heart.61  Other  sugars  have 
less  action.  Their  nutritive  effect  apparently 
runs  parallel  with  their  susceptibility  to  fer- 
mentation, glucose  standing  far  ahead  of  the 
others.62 

Sugar  Treatment  of  Failing  Heart. — The 
nutritive  power  of  sugar  has  been  utilised  in 
cases  of  cardiac  weakness  by  Dr  Goulston,  and 
the  effects  of  large  quantities  of  sugar  adminis- 
tered daily  are  sometimes  extraordinarily  good. 
The  mode  of  administration  was  suggested  by 
Dr  Goulston  &  and  is  described  more  in  detail  by 
Dr  Carter.64  It  consists  in  making  the  patient 
abstain  from  acids,  fats,  fruits  and  sauces, 
and  giving  two  ounces  of  sugar  daily  the  first 
week,  three  ounces  the  next,  and  four  ounces 
the  next  again.  This  quantity  may  be  kept  up 
or  increased.  The  form  of  sugar  used  was 
"  Glebe  granulated  "  cane  sugar.  Probably  other 
forms  of  pure  cane  sugar  would  answer  quite 
well.  I  have,  however,  tried  honey  in  place  of 
sugar,  but  was  obliged  to  discontinue  it  because 
it  caused  acidity  in  the  stomach. 

Purin  Bodies. — We  know  that  a  fire  when 
allowed  to  burn  without  attention  will  often  go 
out  before  the  whole  of  the  coal  is  consumed, 
because  it  is  smothered  in  its  own  ash,  and  that 
if  we  heap  ashes  on  the  fire  we  tend  to  put  it 
out.  But  the  result  is  different  if  we  use  cinders 


288    CARDIAC  AND  VASCULAR  REMEDIES 

instead  of  ash ;  and  although  cinders  represent 
half-burned  coal,  they  are  sometimes  very  useful 
in  keeping  up  a  fire  or  in  helping  it  to  burn 
when  it  is  low.  In  the  same  way  the  ashes,  as 
we  may  term  them,  of  the  tissues  tend  to  smother 
the  vital  fires,  and  to  prevent  the  tissues  from 
performing  their  proper  functions  ;  but  the  vital 
cinders,  that  is,  substances  which  are  derived 
from  albumens  and  are  on  the  way  to  urea  or 
uric  acid,  may  be  very  useful. 

Amongst  these  we  have  a  series  of  bodies 
to  which  the  term  of  purin  bodies  has  been 
applied  —  xanthine,  hypoxanthine,  methylxan- 
thine,  dimethylxanthine  or  theobromine,  and 
trimethylxanthine  or  caffeine.  All  these  bodies 
are  probably  injurious  in  large  quantities,  but 
just  as  a  few  cinders  may  help  a  fire,  so  when 
used  in  small  quantities  they  are  often  very 
useful.  Beef-tea  and  extracts  of  meat  have 
little  or  no  nutritive  action,  and  life  cannot  be 
sustained  upon  them,  but  they  are  useful  stimu- 
lants, as  was  shown  by  Parkes  in  the  Ashanti 
campaign  ;65  and  in  disease  they  act  as  cardiac 
stimulants,  though  only  slightly  as  cardiac 
nutrients.  Caffeine  in  large  doses  acts  as  a 
muscular  poison,  and  tends  to  cause  strong  con- 
traction, ending  in  rigor  of  the  muscle.66  Its 
effect  in  small  doses  upon  the  heart  appears  to 
be  that  it  increases  the  muscular  contraction 
and  strengthens  the  ventricular  beats.67 

Cardiac  Tonics.  Cause  of  Normal  Tone. — 
Like  other  involuntary  muscles,  such  as  the 
bladder,  the  heart  possesses  the  quality  of  tone,08 
which  may  be  said  to  be  the  outer  limit  of  its 


CAUSE  OF  NORMAL  HEART  TONE     289 

ordinary  dilatation.  In  the  bladder  we  find 
that  urine  may  gradually  accumulate  up  to  a 
certain  point  without  either  causing  discomfort 
or  desire  to  micturate,  but  if  filled  beyond  that 
point  one  or  other  of  these  sensations  comes  on. 
Yet  if  micturition  is  prevented  the  desire  to 
empty  the  bladder  may  pass  off,  and  it  may  go 
on  filling  still  more  till  it  is  distended  to  a 
considerably  greater  size  before  the  desire  to 
micturate  again  comes  on.  The  bladder  would 
thus  seem  to  have  a  tone  which  can  be  fixed  at 
various  points,  and  something  of  the  same  occurs 
in  the  case  of  the  heart.  The  healthy  heart 
only  dilates  up  to  a  certain  point  and  then 
contracts,  but  the  same  heart  may  undergo  con- 
siderable dilatation  and  then  with  an  increased 
capacity  may  go  on  beating  as  before.  The  tone 
of  the  normal  heart  appears  to  be  maintained 
by  the  internal  secretions  of  certain  glands, 
and  especially  of  the  suprarenal  glands,69  and 
possibly  of  the  pituitary  bodies  which  are  more 
or  less  constantly  poured  into  the  blood.  Adren- 
alin is  constantly  present  in  normal  blood  serum,70 
and  its  power  to  cause  arterial  contraction  is 
shown  by  the  fact  that  when  strips  of  artery  are 
put  into  Ringer's  solution  they  contract  on  the 
addition  of  normal  serum  to  it.71  The  amount 
of  adrenalin  in  mixed  blood  is  smaller  than  in 
the  blood  of  the  suprarenal  vein.  In  diseases 
of  the  suprarenal  gland,  when  the  medullary 
portion  alone  is  affected,  the  heart  loses  both  its 
tone  and  contractility  and  the  arterial  pressure 
is  greatly  reduced,  but  there  is  no  discoloration 
of  the  skin,  whereas  if  the  cortical  substance  is 


290  LITERATURE 

affected  the  peculiar  bronzing  characteristic  of 
Addison's  disease  occurs  in  addition.72 


LITERATURE. 

1  Schmiedeberg,  Ber.  d.  sacks.  Gesellsch.  d.  Wiss.,  math.- 

phys.  Cl.,  1870,  p.  135  et  seq.;  and  Lud-wig's  Arbeiten, 

1870,  p.  46. 

2  Bowditch,   Ber.   d.  sticks.    Gesellsch.   d.    Wiss.,  muth.- 

phys.  Cl.,  1871,  p.  655  ;  and  Ludwig' s  Arbeiten  for 

1871,  p.  142. 

3  Lauder  Brunton,  Brit.  Med.  Journ.,  1871,  vol.  ii.,  p.  687  ; 

Collected  Papers  on  Circulation  and  Respiration, 
p.  305  ;  and  Experimental  Investigation  of  the  Action 
of  Medicines,  p.  72  (London:  Churchill,  1875). 

4  Kronecker,   Beitrage  z.   Anat.    u.    Physiol.    Festgabe, 

Carl  Ludwig  gewidmet,  Leipzig,  1874,  pp.  174 
and  175. 

5  Kronecker,  Catalogue  of  Scientific  Appliances,  Exhibi- 

tion at  South  Kensington,  1876. 

6  F.  Williams,  Arch.  f.  exp.  Path.  u.  Pharm.,  1880,  vol. 

xiii.,  p.  I. 

7  Lauder    Brunton,    Bericht.    d.   math.-phys.   Classe  der 

konigl.  sacks.  Gesellsch.  d.  \Viss.,  1869,  p.  285  ;  and 
Ludwigs  Arbeiten^  4ter  Jahrg.  fur  1869,  p.  101. 

8  Lauder  Brunton,  Brit.  Med.  fourn.,  1871,  3rd   June, 

vol.  i.,  p.  581,  etc.  ;  Experimental  Investigation  of 
:  the  Action  of  Medicines,  p.   84  et  seq.   (London : 
Churchill,  1875). 

9  Mosso,  Ludvuig's  Arbeiten,  1874,  p.  305. 

10  Carl  Ludwig,  Ztschr.f.  rat:  Med.,  1846,  vol.  v. 

11  H.  Newell  Martin,  Phil.  Trans.,  1883,  vol.  clxxiv.,  p. 

666. 

12  Langendorff,  P finger's  Archiv,  1895,  vol.  Ixi.,  p.  291. 

13  Locke,  Journ.  of  Physiol.,   1895,  vol.  xviii.,   p.    332  ; 

Ringer,   ibid.,  vol.   Hi.,    1880-82,   p.    380,    vol.    iv., 
1883-84,  pp.  29  and  222. 
M  Ehrlich,  Therap.  Monatsh.,  Marz  1887,  p.  90. 


LITERATURE  OF  CHAPTER  XI         291 

lft  Nothnagel  and  Rossbach,  Arzncimittellehre,  p.  755, 
6th  Aufl.  1887;  V.  Bezold,  Untersuch.  d  Physiol. 
Labor.,  Wiirzburg,  Bd.  i.  ;  Schmiedeberg,  Ludwig's 
Arbeiten,  1870 ;  Schmiedeberg,  Grundriss  d. 
Pharmakol. 

16  Cl.    Bernard  and    Pelouze,   Compt.  rend.,    1850,  vol. 

xxxi.,  p.  533  ;  Bernard,  Lemons  s.  1.  Ejffels  des  Sub- 
stances Toxiques,  p.  329  (Paris,  1857) ;  Tillie,  Arch 
f.  exp.  Path.  u.  Pharm.,  1890,  vol.  xxvii.,  p.  27. 

17  Langley  and  Dickinson,  Journ.  of  Physiol.,  1890,  vol. 

xi.,  p.  278 ;  Langley  (pre-ganglionic  and  post- 
ganglionic  fibres),  ibid.,  1894,  vol.  xv.,  p.  178  ;  and 
Langley,  Schafer's  Textbook  of  Physiol.,  1900,  vol.  ii., 
p.  616  et  seq. 

18  Dixon  and   Ransom,   Ergeb.  d.  Physiol.,  1912,  I2th 

Jahrb.,  p.  765  et  seq.  (Wiesbaden  :  Bergmann). 

19  Percy,     An    Experimental   Enquiry  concerning   the 

Presence  of  Alcohol  in  the  Ventricles  of  the  Brain 
after  poisoning  with  that  liquid,  together  with 
Experiments  illustrative  of  the  Physiological  Action 
of  Alcohol  (London,  1839). 

20  Authors  quoted  by  Hans  Meyer,  Arch.f.  Exp.  Path.  u. 

Pharm.,  1899,  v°l-  xli'-»  P-  IO9  et  seq. 

21  Hans  Meyer,  op.  cit.  and  ibid.,  1901,  vol.  xlvi.,  p.  338. 

22  }L.Ovtv\.on,StudtenuberNarkose(]&na.:  Fischer,  1901). 

Literature,  Meyer  and  Gottlieb's  Pharmakologie,  p. 
90,  etc. 

23  Lauder  Brunton,   Ludwig's  Arbeiten,  4th   Jahrg.  for 

1869  (Leipzig,  1870),  p.  ill  ;  Filehne,  Arch.  f.  Anat. 
u.  Physiol.,  1879,  p.  386  ;  and  P  finger's  Archiv,  1874, 
vol.  ix.,  p.  470. 

24  Gottlieb,  op.  cit.,  pp.  213  and  233. 

26  Traube,  Charitc  Annalen,  1851,  and  Gesammelte 
Beitrage,  1871,  vol.  i.,  p.  194  (Hirschwald  :  Berlin). 

26  Nothnagel  and  Rossbach,  Arzneimittellehre,  p.  763, 

6th  Aufl.  (Berlin,  1887). 

27  Claude  Bernard,  Compt.  rend.,  1864,  vol.  lix.,  p.  413. 

Crum-Brown  and  Fraser,  Trans.  Roy.  Soc.,  Edinburgh, 
6th  Jan.  1868.  For  literature,  see  H.  C.  Wood, 
Therapeutics,  8th  ed.,  p.  177  (Philadelphia,  1891); 
and  Th.  Huserriann,  Arch.  f.  exp.  Path.  u.  Pharm., 
1878,  vol.  ix.,  p.  414  et  seq. 


292  LITERATURE 

38  Schmiedeberg    u.    Koppe,   Das  giftige  Alkaloid  des 

Fliegenpilzes  (Leipzig,  1869). 
28  Schmiedeberg,  Lud-wig's  Arbeiten  for  1870,  p.  45. 

30  Schmiedeberg,  Arch.  f.  exp.  Path,  u.  Pharm.,  1881, 

vol.  xiv.,  p.  377. 

31  Schmiedeberg,  Arch.  f.  exp.  Path,  u,  Pharm.,  1875, 

vol.  iii.,  p.  1 8. 

88  Brunton    and   Cash,    Ueber    vorbeugende  Gegengifte, 
Centralb.  d.  med.  Wiss.,  1884,  p.  545. 

33  Brunton  and  Cash,  St  Bartholomew's  Hospital  Reports, 

1885,  vol.  xx. 

34  Hans  Meyer,  Brit.  Med.  Journ.,  1910,  vol.  ii.,  p.  1594. 

36  Straub,  P finger's  Archiv,  1907,  vol.  cxix.,  p.  127. 

38  P.  Ehrlich,  Das  Sauerstoff  Bediirfniss  des  Organismus 
(Berlin  :  Hirschwald,  1885). 

37  Brunton    and    Cash,  Practitioner,   1884,   vol.    xxxiii., 

p.  272. 

38  Luciani,  Ludwigs  Arbeiten  for  1872,  p.  187. 

39  Gnauck,  Ver.  d.  physiol.  Gesellsch.  zu  Berlin,  1881. 

40  Schapiro,  Centralb.  d.  med.  Wiss.,  1884,  p.  577. 

41  Brunton  and  Cash,  Journ.  of  Physiol.,  1883,  vol.  iv., 

p.  i. 
12  Luciani,  op.  cit.,  p.  187. 

43  Ringer,  Journ.  of  Physiol.,  1880-82,  vol.  iii.,  p.  115. 

44  Pantelejeff,  Centralb.  f.  d.  med.  Wiss.,  p.  529,  1880. 

46  Brunton  and  Cash,  St  Bartholomew's  Hospital  Reports, 
1885,  vol.  xx. 

46  Johannsen,  Diss.  Dorpat,  1869,  quoted  by  Schmiede- 

berg. 

47  Aubert,  P finger's  Archiv,  1872,  vol.  v.,  p.  598. 

48  Schmiedeberg,  Arch.  f.  exp.  Path.  u.  Pharm.,  1874, 

vol.  ii.,  p.  62  et  seq. 

49  Brunton    and    Cash,   Centralb.  d.   med.    Wiss.,    l8«6, 

p.  241  ;  and  Beitrage  zur  Physiol.,  Carl  Ludwig 
zu  seinem  siebzigsten  Geburtstage  gewidmet  von 
seinen  Schiilern,  1887,  p.  149^  seq.  (Leipzig  :  Vogel). 

50  Ludwig's  Arbeiten  for  1866,  p.  80;  for  1869,  p.  178; 

for  1870,  p.  44  ;  for  1871,  p.  144  ;  for  1872,  p.  114. 
81  Rossbach,  Ludwig's  Arbeiten  for  1874,  p.  94  ;  Stie"non, 

ibid.,  1878;   and  Arch.  f.  Anat.  u.  Physiol.,  1878, 

p.  269. 
to  Merunovicz,  Ludwig 's  Arbeiten  for  1875,  p.  173  et  seq. 


LITERATURE  OF  CHAPTER  XI         293 

53  Ringer,  Journ  of  Physiol.,  1885,  vol.  vi.,  p.  362. 

54  Ringer,  op,  cit.,  p.  381. 

66  C.  W.  Greene,  Amer.  Journ.  of  Physiol.,  1899,  vol.  ii., 

p.  102. 
56  Ringer,  op.  cit.,  1880-82,  vol.  iii.,  p.  389. 

67  Hovvell,  Amer.  Journ.  of  Physiol.,  1899,  vol.  ii.,  p.  80. 

58  Howell  and  Duke,  Amer.  Journ.  of  Physiol.,   1908, 

vol.  xxi.,  p.  51. 

59  Kronecker,  Ludwigs  Festgabe,  1874,  p.  200. 

60  Martius,   Archiv  f.   Anat.  u.  Physiol.,  physiol.  Abt., 

1883,  p.  562  ;  and  Kronecker's  Arbeiten,  1883. 

61  Locke,  Journ.  of  Physiol.,  1895,  vol.  xviii..  p.  332. 

62  Locke,  Centralb.  f.  Physiol.,   1901,  vol.  xiv.,  p.  670 ; 

Proc.  of  Physiol.  Soc.  in  Journ.  of  Physiol.,  vol. 
xxxi.,  p.  xiii.  ;  Locke  and  Rosenheim,  Journ  of 
Physiol.,  1007,  vol.  xxxvi.,  p.  205. 

63  Goulston,  Brit.  Med.  Journ.,  1911,  vol.  i.,  p.  615. 

64  Carter,  Brit.  Med.  Journ.,  1911,  vol.  ii.,  p.  1401. 

65  E.  A.  Parkes,  On  the  Issue  of  a  Spirit  Ration  during 

the  A shanti  Campaign  (London  :  Churchill,  1875). 

66  Schrniedeberg,  Arch.  f.  exp.  Path.   u.  Pharm.,  1874, 

vol  ii.,  p.  62  ;  Brunton  and  Cash,  Journ.  of  Physiol., 
1888,  vol.  ix.,  p.  112. 

67  Dreser,  Arch.   f.  exp.   Path.   u.   Pharm.,    1888,   vol. 

xxiv.,  p.  240. 

68  Gaskell  in  Schafer's  Textbook  of  Physiol.,  1900,  voK  ii., 

p.  194. 

69  Cybulski,  abstract  in  Centralbl.  /.  Physiol.,  1895,  vol. 

ix.,  p.  174. 

70  Ehrmann,  Arch.  f.  exp    Path.  u.  Pharm.,  1905,  vol. 

liii.,  p.  no. 

71  Douglas  Cow,  Journ.  of  Physiol.,  1911,  vol.  xlii.,  p.  132. 

72  Gibson,   Brit.   Med.  Journ.,  27th   July   1912,  p.   167. 

For  a  full  account  of  the  suprarenal  bodies,  with 
literature,  vide  Swale  Vincent,  Internal  Secretion 
and  the  Ductless  Glands  (London  :  Edward  Arnold, 
1912),  and  The  Internal  Secretory  Organs:  Their 
Physiology  and  Pathology,  by  Prof.  Artur  Biedl, 
Transl.  by  L.  Forster,  1912.  (London  :  John  Bale, 
Sons,  and  Danielsson). 


CHAPTER  XII 

ACTION   OF  CARDIAC  TONICS 

Cardiac  Stimulants  —  Digitalis — Historical  Sketch  — 
Action  of  Digitalis  on  the  Frog's  Heart — Action  of 
Cardiac  Tonics  on  the  Embryonic  Heart — Action  of 
Digitalis  on  Mammals — On  the  Mammalian  Heart — 
On  the  Arterioles — Stages  in  the  Action  of  Digitalis 
— Toxic  Action  of  Digitalis — Action  of  Digitalis  on 
the  Kidney — Resume  of  the  Action  of  Digitalis — • 
Uses  of  Digitalis — Action  of  Digitalis  on  O2dema— 
Congeners  of  Digitalis — Differences  between  Digi- 
talis and  other  Cardiac  Tonics — Drawbacks  to  the 
Action  of  Digitalis  and  other  Cardiac  Tonics — 
Removal  of  these  Drawbacks — Digitalis  in  Cases 
of  Fatty  Heart — Action  of  Adrenalin  on  the  Heart 
and  Vessels — Action  of  Camphor — Action  of  Strych- 
nine on  the  Heart — Action  of  Caffeine  and  other 
Purin  Bodies — Action  of  Pituitary  Gland. 

Cardiac  Stimulants. — It  is  almost  impossible 
to  draw  a  sharp  line  between  cardiac  tonics  and 
cardiac  stimulants,  as  the  same  drugs  that  tend 
to  maintain  cardiac  tone  arid  prevent  excessive 
dilatation  have  also  the  power  of  increasing  the 
contractile  power  of  the  heart  in  its  ordinary 
pulsations.  The  most  typical  example  of  this 
class  of  drugs  is  digitalis.  There  are,  however, 
many  other  plants  which  possess  active  prin- 
ciples very  nearly  allied  to  those  of  digitalis  and 

294 


HISTORY  OF  DIGITALIS  295 

having  a  physiological  action  more  or  less  like  it. 
It  is  now  generally  recognised  that  digitalis  has 
(i)  the  power  of  slowing  the  heart,  (2)  of  making 
it  stronger,  (3)  and  of  contracting  the  vessels. 

Historical  Sketch  of  the  Action  of  Digitalis. 
— It  is  only,  however,  within  the  last  half-century 
that  this  view  has  been  adopted.  So  long  ago 
as  1839,  James  Blake,  at  Professor  Sharpey's 
suggestion,  made  some  manometric  experiments 
with  digitalis.  By  injecting  infusion  of  digitalis 
into  the  carotid,  so  that  it  passed  into  the  general 
circulation  before  reaching  the  heart,  he  found  it 
produced  a  very  great  rise  in  the  arterial  tension, 
and  therefore  concluded  that  it  contracted  the 
capillaries.1  His  experiments  attracted  little 
attention,  and  no  additions  were  made  to  our 
knowledge  of  the  drug  until  Traube  began  the 
remarkable  series  of  experiments  which  laid 
the  foundation  for  an  accurate  knowledge  of 
its  mode  of  action,  and  consequently  of 
its  therapeutical  application.  Traube  found 
that  it  slowed  the  heart  and  increased  the 
blood-pressure.  He  proved  that  this  slowing 
was  due  to  a  central  action  upon  the  vagus,  but 
he  attributed  the  rise  of  blood-pressure  entirely 
to  increased  action  of  the  heart.2  That  such 
action  does  contribute  to  the  rise  of  blood- 
pressure  there  can  be  little  doubt,  but  it  is  not 
the  main  cause.  Traube  also  discovered,  in 
1865,  that  digitalis  had  an  action  on  the  vaso- 
motor  nerves  (Digitalis  wie  ich  nachtraglich 
gefunden  habe,  auch  auf  das  vasomotor  Nerven- 
system  erregend  wirkt).3  To  him,  therefore, 
belongs  the  priority  of  the  discovery  of  the 


296          ACTION  OF  CARDIAC  TONICS 

action  of  digitalis  on  the  arterioles  as  well  as  on 
the  heart ;  and,  taken  along  with  his  previous 
work,  this  passage  shows  that  he  had  obtained  a 
complete  knowledge  of  the  action  of  the  drug, 
yet  he  did  not  formulate  it  in  its  entirety  until 
1871.*  I  think,  therefore,  that  the  first  com- 
plete description  of  the  physiological  action  of 
digitalis  is  that  which  I  gave  myself  in  the 
thesis  which  I  presented  to  the  University  of 
Edinburgh  in  i866.5  I  subjoin  here  the  chief 
points  of  this  thesis,  which  I  communicated  to 
my  friend  Professor  Rutherford,  and  which  he 
published  in  The  Journal  of  Anatomy  and 
Physiology \  vol.  i.,  1867,  p.  154.  "It  acts  as  a 
diuretic  even  in  health.  Poisonous  doses  first 
occasion  diminished  frequency,  but  increased 
strength  of  the  cardiac  pulsations,  together  with 
contraction  of  the  capillaries.  The  slackening 
of  the  heart's  speed  is  due  to  the  direct  action  of 
poison  upon  the  heart,  and  not  to  the  increased 
resistance  offered  by  the  contracted  capillaries. 
After  a  short  time  the  pulse  becomes  irregular, 
the  capillaries  dilate,  the  arterial  tension  dimin- 
ishes, and  syncope  is  apt  to  supervene.  Lastly, 
the  pulse  becomes  very  rapid,  and  stoppage  of 
the  heart  in  a  state  of  contraction  soon  follows." 
Action  of  Digitalis  on  the  Frog's  Heart. — 
Its  action  upon  the  heart  of  the  frog  is  very 
marked  and  characteristic,  and  the  action  here 
is  less  complicated  than  in  mammals,  inasmuch 
as  the  heart  itself  is  less  under  the  control  of 
the  central  nervous  system,  and  is  less  readily 
affected  by  alterations  which  may  occur  in  the 
vessels.  When  the  excised  heart  of  a  frog  is 


297 

either  laid  in  a  solution  containing  the  active 
principles  of  digitalis,  or  is  connected  with  an 
apparatus  by  which  serum  containing  these 
principles  may  be  circulated  through  it,  changes 
are  observed,  which  may  be  divided  into  changes 
in  rate  of  pulsation  and  changes  in  character  of 
pulsation.  The  heart  first  of  all  begins  to 
pulsate  more  slowly,  and  at  the  same  time 
more  powerfully ;  the  contractions  become 
gradually  stronger,  and  the  relaxation  or 
diastole  becomes  less  perfect,  so  that  finally 
the  heart  stands  still  altogether  in  a  state 
of  complete  contraction.  If  the  heart  which 
is  thus  standing  still  be  forcibly  dilated,  by 
passing  fluid  into  its  interior  under  pressure, 
pulsation  will  recommence.6  Occasionally 
during  the  process  of  contraction  small  points 
on  the  surface  of  the  heart  may  be  observed, 
which  remain  dilated,  and  look  like  small  purple 
pulsatile  pouches  on  the  surface  of  the  organ.7 
The  nature  of  these  pouches  has  not  been 
definitely  ascertained,  but  it  is  not  improbable 
that  they  are  due  to  slight  injury  of  the 
muscular  fibre  in  the  process  of  removing  the 
heart  from  the  body  of  the  frog.  When  the 
heart  of  a  frog  is  left  in  situ,  and  is  merely 
exposed  to  view  by  opening  the  thorax  of 
the  animal  and  dropping  a  solution  of  digitalis 
upon  it,  the  same  phenomena  are  observed. 
They  are  unaltered  by  the  use  of  atropine,  and 
are  supposed  to  be  due  to  the  action  of  the 
drug  upon  the  muscular  fibres  of  the  heart  itself. 
Mode  of  Action  of  Cardiac  Tonics  on  the 
Embryonic  Heart ;  Relation  of  their  Action 


298          ACTION  OF  CARDIAC  TONICS 

to  Oxidation. — J.  W.  Pickering  has  found  that 
digitalis  has  the  same  action  on  the  embryonic 
as  on  the  adult  heart,  rendering  the  systole 
very  powerful  and  the  diastole  imperfect,  so 
that  at  last  the  heart  stops  in  tonic  contrac- 
tion, and  becomes  very  pale.  Caffeine  slightly 
increases  both  the  frequency  and  energy  of  the 
systoles,  and  finally  causes  stoppage  in  systole.8 
He  points  out  (p.  436)  that  the  action  of  these 
two  drugs  on  the  heart  may  be  due  to  their 
effect  upon  oxidation,9  for  they  are  par  excellence 
the  drugs  which  produce  tonic  contraction,  and 
as  Cash  and  I  have  shown,  they  accelerate  the 
oxidation  of  protoplasm.10  Other  drugs  which 
retard  oxidation  tend  to  produce  an  atonic  con- 
dition of  the  embryonic  heart. 

Action  of  Digitalis  in  Mammals.  —  In 
mammals,  digitalis  causes  increased  contrac- 
tion of  the  muscular  fibres,  both  (i)  in  the 
heart,  and  (2)  the  arteries.  This  increased 
contraction  appears  to  be  partly  due  to  the 
action  of  digitalis  on  the  muscular  fibres  them- 
selves, but  its  effect  upon  the  muscle  is  greatly 
modified  by  its  action  upon  the  nervous  system. 
Its  action  is  exerted  especially  upon  the 
medulla  oblongata,  and  it  appears  to  affect 
first  the  inhibitory  centre  of  the  vagus  and 
the  vaso-motor  centre  for  the  vessels.  When 
small  doses  are  given,  the  effect  appears  to 
be  limited  to  these  centres,  but  when  the 
administration  is  carried  to  the  extent  of 
poisoning,  the  adjacent  respiratory  and  vomit- 
ing centres  are  also  affected. 

Action    of    Digitalis     on    the     Mammalian 


DIGITALIS  ON  MAMMALS         ±<$ 

Heart. — The  action  of  digitalis  on  the  mam- 
malian heart  when  isolated  from  the  body  and 
perfused  with  a  nutrient  solution  is  to  first  slow 
and  then  accelerate  its  pulsations.11  It  increases 
the  force  as  well  as  the  frequency  of  its  systolic 
contraction,12  and  at  the  same  time  it  causes 
the  dilatation  during  diastole  to  become  more 
complete,  so  that  the  actual  work  done  by  the 
heart  may  be  increased  to  more  than  three 
times  its  former  amount.13 


100 


JO 


60 


Pio.  90.— Kymographic  tracings  of  the  blood-pressure  in  a  dog  under  the 
influence  of  digitalis.  7.  shows  the  normal  curve,  II.  and  ///.  show  the 
slowing  of  the  pulse  and  rite  of  blood-pressure  produced  by  the  drug. 
(Brunton  and  A.  B.  Meyer. ) 

Action  of  Digitalis  on  Arterioles. — The  rise 
of  blood-pressure  which  digitalis  produces  was 
attributed  by  Traube  and  von  Bezold  to 
increased  action  of  the  heart,  and  they  left  the 
arterioles  altogether  out  of  account  as  a  factor 
in  its  production.  In  my  thesis,  presented  to 
the  Edinburgh  University  in  1866,  I  pointed 
out  the  importance  of  the  arterioles,  and  in 
the  winter  of  1867-68  I  obtained,  in  conjunction 
with  A.  B.  Meyer,  experimental  evidence  of 


300  ACTION  OF  CARDIAC  TONICS 


FIG.  91.— Normal  tracing  of  the  blood-pressure  in  a  dog  during  stoppage 
of  the  heart  by  electrical  stimulation  of  the  vagus.  0  0  marks  the 
duration  of  the  stimulation.  It  will  be  noticed  that  during  the 
stoppage  the  blood-pressure  falls  to  within  1*5  cm.  of  the  abscissa. 
The  latent  period  of  the  vagus  is  also  shown,  a  complete  pulse  occurring 
between  the  commencement  of  stimulation  and  stoppage  of  the  heart. 
The  long  duration  of  the  vagus  action  is  also  shown,  pulsation  not 
recommencing  until  a  considerable  time  after  stimulation  has  ceased. 


Fiu.  92.— The  same  experiment  as  in  Fig.  91,  but  after  the  injection  of 
digitalis.  Although  the  arrest  of  the  heart  is  longer  than  in  the 
previous  experiment,  the  blood-pressure  only  falls  to  within  8  cm.  of 
the  abscissa  instead  of  to  1*5  cm.  The  action  of  digitalis  is  also  seen 
in  the  slower  and  larger  beats  before  the  heart  stops. 


STAGES  IN  ACTION  OF  DIGITALIS     301 

this  action,  using  the  identical  kymograph 
which  Traube  had  employed.12  We  noticed 
that  after  the  injection  of  digitalis  into  the  veins 
of  a  dog,  the  pressure  in  the  arteries  not  only 
rose  higher  than  before,  but  it  fell  more  slowly 
during  diastole.  Had  the  arterioles  not  been 
contracted,  the  higher  pressure  would  have 
driven  the  blood  more  quickly  through  them 
in  diastole,  and  so  the  fall  would  have  been 
quicker  than  before,  instead  of  being  slower, 
as  we  found  it  to  be.  In  order  to  obtain  more 
certain  proof  of  this,  however,  I  then  took  up 
the  question  along  with  Dr  Tunnicliffe,  and 
instead  of  using  the  normal  systole  of  the  heart 
we  prolonged  it  greatly  by  irritation  of  the  vagus. 
The  results  we  arrived  at  entirely  confirmed 
my  previous  observations;  for,  although  the 
pressure  was  considerably  raised  in  the  arteries 
by  the  administration  of  digitalis,  it  fell  very 
much  more  slowly  than  in  the  normal  animal, 
while  the  heart  was  standing  still  from  irrita- 
tion of  the  vagus.  I  need  not  enter  further 
into  the  discussion  of  this  point,  as  Tunni- 
cliffe and  I  have  gone  fully  into  it  in  our 
paper.18 

Stages  in  the  Action  of  Digitalis.  —  The 
action  of  the  drug  may  be  divided  into  several 
stages.  These  stages  have  been  variously 
described,  so  that  the  stages  of  different  authors 
do  not  correspond.  The  essential  part  of  the 
division  is  that  in  the  first  stage  there  is  increased 
power,  both  of  those  parts  of  the  nervous  system 
connected  with  the  heart  and  vessels  and  of  the 
muscular  fibres  in  them,  while  in  the  later  stages 


302  ACTION  OF  CARDIAC  TONICS 

more  or  less  complete  paralysis  of  these  struc- 
tures occurs. 

We  might,  then,  take  as  the — 

ist  stage,  that  in  which  there  is  increased  action 
in  all  the  nervous  and  muscular  structures 
concerned  in  the  circulation ; 

2nd,  that  in  which  the  nervous  system  of  the 


Pio.  93. — Tracing  of  blood-pressure  showing  the  effect  of  digitalis.  Section 
1,  normal;  2,  glowing  of  heart,  slight  rise  of  blood-pressure;  8, 
paralysis  of  vagus,  rapid  pulse,  greater  rise  of  pressure;  4,  dilated 
vessels  and  fall  of  blood-pressure.  (Brunton  and  Tunnicliffe.) 

heart  begins  to  fail,  while  muscular  power  and 
the  whole  vascular  apparatus  are  still  intact ; 

3rd,  that  in  which  the  muscular  fibre  of  the 
heart  begins  to  fail  ; 

4th,  that  in  which  the  vessels  becomfc  enfeebled. 

In  the  first  stage  (Section  2,  Fig.  93)  we  have  a 
rise  of  blood-pressure  and  usually  a  slowing  of  the 


TOXIC  ACTION  OF  DIGITALIS         303 

• 

pulse,  this  slowing  being  due  to  the  action  of  the 
drug  both  on  the  vagus  roots  and  ends  in  the 
heart.  Although  the  pulse  is  slow,  the  systole  of 
the  heart  is  not  prolonged,  and  there  is,  therefore, 
a  much  longer  diastole  during  which  the  heart  is 
able  to  rest.  The  blood-pressure  in  the  kidneys 
is  increased  as  well  as  in  the  other  organs,  and 
the  urinary  secretion  is  therefore  augmented. 
In  the  second  stage  (Section  3,  Fig.  93)  while  the 
blood-pressure  continues  high,  the  vagus  becomes 
partially  paralysed,  and  therefore  the  pulsations 
become  at  first  irregular  and  afterwards  very 
rapid.  In  this  condition  spasm  of  the  renal 
vessels  may  occur,  and  the  urinary  secretion 
may  entirely  cease.  When  this  occurs  in  man, 
the  condition  of  the  patient  is  dangerous.  In 
the  third  stage  (Section  4,  Fig.  93)  the  heart 
becomes  feebler,  and  may  again  become  regular, 
from  failure  either  of  the  muscular  fibre  itself 
or  the  intrinsic  ganglia.  The  arterioles  now 
relax,  the  blood  -  pressure  begins  to  fall,  and 
the  urine  may  again  become  copious.  In  the 
fourth  stage,  the  vessels  dilate  generally,  blood- 
pressure  falls  very  greatly,  and  the  heart  stops 
sometimes  in  systole,  as  in  the  frog,  but  very 
frequently  in  diastole. 

Toxic  Action  of  Digitalis. — When  pushed  too 
far  it  produces  poisoning,  and  one  of  the  first 
symptoms  is  nausea  and  vomiting.  This  may 
be  due  simply  to  extension  of  the  irritation  in 
the  medulla  from  the  vagus  and  vaso-motor 
centres  to  the  vomiting  centre ;  but  it  may  be 
due  also,  to  some  extent,  to  a  local  irritation  of 
the  stomach  by  the  digitalis  being  secreted  into 


304          ACTION  OF  CARDIAC  TONICS 

it,  in  the  same  way  as  tartar  emetic,  or  the  toxins 
of  cholera.  In  medical  practice,  gastric  irritation 
is  usually  one  of  the  first  indications  that  the 
physiological  effect  of  digitalis  is  passing  into 
its  toxic  action.  Sometimes,  however,  the  pulse 
becomes  abnormally  slow,  even  before  sickness 
occurs.  If  the  warning  given  either  by  sickness 
or  by  the  pulse  is  attended  to,  and  the  adminis- 
tration of  the  drug  is  stopped,  usually  no  further 
disadvantage  occurs;  but  if  these  warnings  be 
unheeded, the  vagus  becomes  paralysed,the  pulse 
becomes  irregular  or  abnormally  rapid  (Fig.  93), 
excessive  vomiting  may  set  in,  collapse  may 
occur,  and  the  secretion  of  urine  may  be  entirely 
arrested.  The  secretion  of  urine  may  cease 
at  the  time  when  the  blood-pressure  is  at  its 
maximum,  as  I  found  along  with  Mr  Power 
in  the  case  of  digitalis,14  and  along  with  Mr 
Pye  in  the  case  of  erythrophlceum 16  (Fig.  99). 
The  stoppage  of  secretion  is  exactly  like  that 
which  occurs  from  ligature  of  the  renal  artery, 
and  in  all  probability  it  is  due  to  spasm  of  these 
arteries  stopping  the  circulation  through  the 
kidney.14  As  the  pressure  begins  to  fall  and 
the  arteries  relax,  urine  is  again  secreted,  but 
it  is  often  albuminous,  exactly  like  the  urine 
secreted  after  the  arteries  have  been  ligatured 
and  then  released.1* 

In  the  case  of  poisoning  by  digitalis  which  I 
described  in  my  thesis,  the  pulse  had  been 
extremely  rapid  before  I  saw  the  patient. 
When  I  took  the  first  tracing  (Fig.  94)  the 
vagus,  which  had  been  paralysed,  was  beginning 
to  reassert  its  power  over  the  heart,  and  although 


ACTION  OF  DIGITALIS  ON  KIDNEYS  305 

the  pulse  was  still  quick,  occasional  slow  beats 
were  interposed.  As  the  vagus  regained  its 
power  the  pulse  became  slow  with  an  occasional 
quick  beat  interpolated  (Fig.  95),  and  finally  the 
pulse  became  slow  and  regular  (Fig.  98) ;  the 


PIG.  94. — Pulse  tracing  from  a  case  of  poisoning  by  digitalis,  shoving 
quick  pulse  with  slow  beats  interposed. 


FIG.  95. — Same  case. — Recovering  from  the  effects  of  the  poison,  aad 
showing  slow  pulse  with  occasional  quick  beats. 


a. 


c  a, 


FIG.  96.— Same  case.— Slow  pulse,  with  beat  interpolated  at  b. 


FIG.  97.— Same  case.— Pulse  regular,  but  quickened  by  food. 


FIG.  98. — Same  case. — Recovering ;  pulse  slow  and  regular. 


slowness  of  the  pulse  is  probably  due  to  the 
vagus  causing  a  certain  degree  of  heart-block 
(Fig.  50,  p.  145). 

Action  of  Digitalis  on  the  Kidneys. — It  has 
already  been  mentioned  that  the  vaso-motor 
centre  has  the  function  of  distributing  blood 
to  different  parts  of  the  body,  so  that  while  one 


306  ACTION  OF  CARDIAC  TONICS 

contracts  another  dilates.  In  consequence  of 
this  very  great  differences  indeed  may  occur  in 
the  circulation  in  different  parts  of  the  body 
without  any  alteration  in  the  general  blood - 
pressure.  This  appears  to  be  the  case  with 


Fio.  99. — Diagram  to  show  the  relation  between  blood-pressure  and  the 
secretion  of  urine  after  the  administration  of  erythrophloeum.  The 
lower  tracing  shows  the  blood-pressure  in  millimetres  of  mercury. 
The  upper  shows  the  secretion  of  urine  in  minims  per  ten  minutes. 
It  is  to  be  noted  that  when  the  blood-pressure  rises  to  its  maximum 
of  200,  the  secretion  of  urine  falls  to  zero.  (Brunton  and  Pye.) 

digitalis,  which  tends  to  contract  the  vessels  in 
the  splanchnic  area  and  at  the  same  time,  or 
even  before  this,  to  dilate  those  of  the  kidney.16 
If  the  circulation  through  this  organ  is  very 
greatly  increased  the  pressure  upon  the 
glomeruli  rises  and  the  urine  is  secreted 


RESUME  OF  ACTION  OF  DIGITALIS    307 

much  more  quickly.  This  abundant  secretion 
may  occur  without  any  rise  in  blood-pressure. 
When  the  digitalis  is  exerting  its  full  action 
upon  the  arterioles  so  that  the  pressure  rises 
very  much,  the  drug  instead  of  increasing  the 
secretion  of  urine  may  stop  it  altogether, 
producing  in  fact  the  same  effect  as  ligature 
of  the  renal  artery.  When  this  contracting 
effect  of  digitalis  begins  to  pass  off  the  vessels 
of  the  kidney  again  dilate  and  the  secretion 
again  becomes  abundant,  just  as  it  would  if  the 
ligature  had  been  removed  from  the  arteries  of 
the  kidney  previously  ligatured.17  The  same 
effect  is  produced  by  other  drugs  of  the  digitalis 
group,  such  as  erythrophloeum  (Fig.  99).18 

Resume  of  the  Action  of  Digitalis. — Digitalis 
acts  on  the  cardiac  muscle,  the  intrinsic  cardiac 
nerves,  and  the  vagus  centre  in  the  medulla. 
It  also  affects  the  arterioles,  causing  them  to 
contract,  and  probably  it  has  upon  them  also  a 
twofold  action,  as  on  the  heart,  stimulating  both 
the  contractile  muscular  walls  and  the  nerves 
which  go  to  them.  From  stimulation  of  the 
vagus  centre20  the  pulse  becomes  slow,  and  the 
diastole  more  complete,21  while  at  the  same  time 
the  stimulation  of  the  muscular  fibre  of  the  heart 
makes  its  contractions  more  powerful.22  Its 
beats  thus  become  much  more  efficient;  the 
longer  intervals  between  them  afford  the 
heart  time  for  recuperation  ;  the  more  complete 
diastole  allows  a  larger  quantity  of  blood  to 
accumulate  in  its  cavities,  the  more  powerful 
systole  drives  this  onward,  so  that  under  the 
influence  of  digitalis  each  cardiac  contraction 


308  ACTION  OF  CARDIAC  TONICS 

may  do  from  two  and  a  half  to  three  and  a  half 
times  what  it  did  before.-3  The  self-massage  of 
the  heart  becomes  more  complete  .(p.  1 54),  and 
all  the  good  effects  which  I  have  mentioned  as 
occurring  from  this  are  noticed  after  the  action 
of  digitalis.  One  consequence  which  is  of 
special  interest  is  its  diuretic  action.  This  is 
partly  due  to  the  rise  in  blood-pressure  which 
it  produces,  and  which  raises  the  pressure  in  the 
glomeruli,  drives  the  blood  more  quickly  through 
the  kidneys,  and  causes  a  more  rapid  secretion 
of  urine.  At  the  same  time  it  is  probable  that 
digitalis  has  a  certain  stimulating  effect  on  the 
secreting  structures  in  the  kidneys  themselves, 
a  stimulation  which  may  extend  also  to  other 
parts  of  the  genito-urinary  tract  This  effect, 
however,  is  not  so  great  as  that  produced  by 
caffeine,  and  the  diuretic  action  of  digitalis  is 
probably  exerted  chiefly  through  the  circulation. 
When  digitalis  acts  upon  a  healthy  man  so  as 
to  produce  diuresis,  the  drain  of  fluid  becomes 
so  great  that,  as  I  have  found  in  my  own 
experiments,  the  thirst  it  induces  becomes 
intolerable,  and  water  must  be  taken  in  order 
to  allay  it19 

In  cardiac  diseases  with  oedema,  or  accumula- 
tion of  fluid  in  the  serous  cavities,  such  drinking 
is  unnecessary,  as  the  fluid  drained  away  from 
the  blood  by  the  kidneys  is  supplied  by  absorp- 
tion from  the  subcutaneous  tissues  or  from  the 
serous  cavities. 

Uses  of  Digitalis.— Not  only  does  the  circula- 
tion in  the  tissues  generally  improve  under 
digitalis,  but  the  nutrition  of  the  heart  is 


USES  OF  DIGITALIS  309 

increased  by  more  efficient  circulation  through 
the  coronary  vessels,  dilatation  is  lessened,  the 
muscular  rings  around  the  auriculo-ventricular 
orifices  contract  more  strongly,  the  mitral  and 
tricuspid  valves  close  them  more  efficiently, 
and  regurgitation  is  lessened.  In  cases  where 
the  valvular  incompetency  is  solely  due  to 
dilatation  and  not  to  changes  in  the  valves 
themselves,  the  incompetency  may  be  com- 
pletely cured  (p.  75). 

The  arteries  likewise  benefit,  as  the  slower 
and  stronger  beats  of  the  heart  increase  the 
self-massage  of  the  artery  in  its  sheath  (p.  156), 
and  the  same  increased  pulsation  aids  the 
circulation  in  the  veins,  as  already  described. 
The  venous  circulation  is  further  aided  by 
increased  suction  power  of  the  heart  (p.  154), 
which  contracts  more  rapidly  and  completely. 
Diminished  regurgitation  combines  with 
increased  circulation  in  the  veins  to  lessen 
venous  congestion,  and  thus  tends  to  increase 
the  secretion  of  urine.  For  venous  congestion 
in  the  kidneys  tends  to  compress  the  arterioles 
and  tubules  in  the  organ,  and  thus  lessen  secre- 
tion ;  and  digitalis,  therefore,  in  cases  of  venous 
congestion  probably  acts  as  a  diuretic  in  four 
ways — ( i )  it  dilates  the  renal  vessels  and  increases 
the  blood-pressure  in  the  glomeruli ;  (2)  it  lessens 
the  resistance  which  the  pressure  of  the  dis- 
tended venous  radicles  in  the  kidney  opposes  to 
secretion ;  (3)  it  probably  acts  as  a  stimulant  to 
the  secreting  cells  of  the  kidney ;  and  (4)  it 
increases  the  volume  of  blood,  and  somewhat 
alters  its  composition  by  causing  absorption  from 


310          ACTION  OF  CARDIAC  TONICS 

cedematous  tissues  and  serous  cavities.  When 
it  causes  absorption  of  ascitic  fluid  from  the 
abdominal  cavity  it  may  act  as  a  diuretic 
in  a  fifth  way,  viz.,  by  lessening  the  resist- 
ance opposed  to  the  secretion  of  urine  by 
the  pressure  of  the  ascitic  fluid  on  (a)  the 
kidney  itself,  and  (b}  on  the  ureters.  From 
this  manifold  action  of  digitalis  as  a  diuretic 
it  is  evident  that  when  its  action  is  once  fairly 
established  in  a  water -logged  patient,  the 
amount  of  urine  secreted  for  some  days  may 
be  enormous. 

Action  of  Digitalis  on  (Edema. — As  I  have 
already  mentioned,  the  diuretic  action  of 
digitalis  may  cause  so  much  water  to  be 
withdrawn  from  the  blood  that  it  produces 
a  consuming  thirst  in  a  healthy  man.24  In 
a  dropsical  one,  the  fluid  lost  through  the 
kidneys  is  made  up  by  absorption  from  the 
tissues,  and  this  is  one  way  in  which  digitalis 
reduces  oedema.  But  it  is  probably  not  the 
only  one.  For  digitalis  stimulates  the  vaso- 
motor  nerves,  and  in  this  way  tends  to  prevent 
the  exudation  of  fluid  from  the  blood-vessels, 
which  produces  cedema.  It  is  universally 
acknowledged  that  venous  obstruction  tends 
to  produce  cedema,  but  at  the  same  time 
cedema  may  occur  without  any  obvious  venous 
obstruction,  as  in  angioneurotic  cedema.  More- 
over, venous  obstruction  may  exist  without 
cedema,  as  was  shown  by  Ranvier,25  who  tied 
the  vena  cava  in  a  dog,  and  found  that  although 
venous  congestion  was  thus  produced  in  both 
legs,  no  cedema  occurred  in  the  leg  where  the 


CONGENERS  OF  DIGITALIS  311 

vaso-motor  nerves  were  left  intact,  but  occurred 
in  the  other  where  the  vaso-motor  nerves  were 
divided. 

Another  benefit  resulting  from  diminished 
venous  congestion  is  improved  digestion  and 
assimilation.  The  liver,  which  under  increased 
venous  pressure  may  have  become  so  swollen 
as  to  reach  even  below  the  umbilicus,  returns 
more  or  less  to  its  normal  size,  and  the  obstacle 
which  had  existed  to  the  return  of  venous  blood 
from  the  stomach  and  intestines,  nearly  all  of 
which  has  to  pass  through  the  liver,  is  removed. 
The  circulation  through  these  organs  becomes 
better,  digestion  and  absorption  improve,  flatu- 
lence is  lessened,  and  the  patient's  nutrition 
improves. 

Congeners  of  Digitalis.  —  Digitalis  is  an 
example  of  a  very  widely  distributed  group 
of  poisons,  many  of  which  are  used  in  various 
parts  of  the  world  for  poisoning  arrows,  either 
for  use  in  the  chase  or  in  war.  Those  which 
are  most  commonly  used  in  medicine  are  the  Stro- 
phanthus  hispidus  and  squill  (Urginea  Scilla). 
Amongst  those  occasionally,  but  less  frequently, 
employed  are  casca  or  sassy  bark  (Erythro- 
phlceum  guineense),  lily  of  the  valley  (Convallaria 
majalis),  Canadian  hemp  (Apocynum  cannabt- 
num\  pheasant's  eye  {Adonis  vernalis], 
Christmas  rose  (Helleborus  niger),  and  Cactus 
grandiflora.  Other  plants  having  a  similar 
action,  but  not  used,  are  Antiaris  toxicaria 
(upas),  Nerium  oleander,  Acocanthera  (oubain), 
Thevetia  grandiflora,  Tanghenia  venenifera,  and 
Coronilla.  A  poison  having  a  similar  action  is 


312  ACTION  OF  CARDIAC  TONICS 

obtained  from  the  skin  of  toads.26  It  is  called 
phrynin,  and  though  not  employed  much  in 
medicine,  it  has  proved  useful.  The  story  is 
told  that  the  husband  of  an  Italian  woman  was 
dying  of  heart  disease,  with  dropsical  limbs  and 
all  the  usual  accompaniments.  As  his  death 
was  so  slow,  his  goodwife  thought  she  would 
quicken  his  journey  into  the  other  world,  and 
accordingly  she  went  into  the  garden,  where 
she  found  several  toads.  These  she  dropped 
into  the  wine  her  husband  was  to  drink ;  but 
instead  of  his  dying  forthwith,  as  she  expected, 
he  began  immediately  to  get  well,  the  phrynin 
from  the  toads'  skin  having  had  upon  him  the 
same  beneficial  effect  that  a  course  of  digitalis 
would  have  had. 

Difference  between  Digitalis  and  other 
Cardiac  Tonics. — The  differences  which  have 
been  observed  between  the  action  of  digitalis 
and  its  congeners  are  that,  while  digitalis  affects 
both  heart  and  vessels,27  the  action  of  strophan- 
thus  appears  to  be  exerted  more  especially  upon 
the  heart,28  increasing  its  power ;  while  that  of 
erythrophloeum  appears  to  be  exerted  more 
upon  the  vessels.29 

Drawbacks  to  the  Action  of  Digitalis  and 
other  Cardiac  Tonics. — All  the  drugs  of  which 
we  have  hitherto  been  speaking  have  a  tendency 
to  cause  contraction  of  the  vessels.  This 
tendency  may  interfere  with  their  beneficial 
effects  by  causing  contraction  of  the  renal 
arteries,  and  thus  checking  the  secretion  of 
urine ;  but  a  greater  drawback  sometimes  is 
that,  by  contracting  the  vessels  generally,  they 


DRAWBACKS  TO  DIGITALIS  313 

raise  the  blood -pressure  and  thus  increase  the 
resistance  which  the  heart  has  to  overcome, 
and  consequently  the  work  it  has  to  do.  If  the 
heart  is  very  feeble,  it  may  even  become  unable 
to  overcome  the  increased  tension,  and  sudden 
and  fatal  syncope  may  ensue.  Fatal  syncope 
has  not  infrequently  resulted  from  the  excessive 
use  of  digitalis,  and  it  appears  to  be  more  apt  to 
come  on  when  the  person  rises  to  micturate. 
The  sudden  change  from  a  recumbent  to  an  up- 
right position  lessens  the  pressure  of  blood  in 
the  cerebral  arteries,  while,  at  the  same  time, 
by  emptying  the  bladder  the  intra-abdominal 
pressure  is  lessened,  and  the  blood  is  retained 
in  the  splanchnic  area.  But  the  cases  in  which 
the  heart  is  most  likely  to  be  stopped  by  digi- 
talis are  those  in  which  the  arterial  pressure  is 
already  high,  as  in  advanced  Bright's  disease,  and 
where  the  heart  has  already  become  fatty.  In 
such  cases  digitalis  must  be  used  with  great 
caution,  for  there  is  a  double  risk.  On  the  one 
hand  there  is  the  danger  just  alluded  to  of 
stopping  the  heart,  and  on  the  other,  there  is 
the  risk  of  causing  apoplexy  by  the  arterial 
tension  rising  so  high  as  to  burst  a  vessel  in  the 
brain. 

Removal  of  these  Drawbacks  by  Combina- 
tion.— Yet  in  many  such  cases  we  sadly  want 
the  steadying  and  strengthening  effect  of 
digitalis  or  strophanthus  upon  the  heart,  and 
we  are  able  to  obtain  the  result  we  desire  by 
combining  these  drugs  with  others  belonging 
to  an  entirely  different  class,  namely,  that  of 
vaso-dilators. 


314  ACTION  OF  CARDIAC  TONICS 

Digitalis  in  Cases  of  Patty  Heart. — In  my 

thesis,  presented  to  the  University  of  Edinburgh 
in  1866,  I  closed  the  part  on  the  use  of  digitalis 
with  the  following  remarks.  "With  just  one 
word  of  warning,  I  will  close  this  brief  summary 
of  the  therapeutical  applications  of  digitalis, 
and  that  is  to  those  who,  thinking  that  there 
can  be  no  danger  in  giving  digitalis  to  those 
with  very  weak  hearts,  and  that  indeed  it 
is  the  best  thing  for  them  to  use  it  indis- 
criminately. I  believe  that  I  have  proved  that 
it  increases  the  force  of  the  cardiac  pulsations ; 
but  if,  while  the  motor  nerves  were  stimulating 
it  to  contract,  and  the  capillaries  at  the  same 
time  were  opposing  a  resistance,  the  fibres  of 
the  heart  itself  were  not  composed  of  sound 
muscle,  but  were  fatty  and  friable,  some  of 
them  would  be  pretty  sure  to  rupture,  and  the 
results  would  be  disastrous.  I  therefore  think 
that,  in  cases  of  fatty  heart,  great  caution  is 
necessary  in  administering  it." 80  This  warning 
has  received  remarkable  confirmation  within 
the  last  few  months,  as  Scalfati 31  has  found  that 
in  dogs  whose  hearts  he  had  rendered  fatty  by 
means  of  phosphorus  the  effects  produced  by 
digalen,  digitalin,  digitoxin  and  strophanthin 
were  in  more  or  less  strict  relation  to  the 
amount  of  fatty  degeneration  present.  When 
this  was  slight  the  effect  was  much  the  same 
as  in  a  normal  heart,  but  if  the  heart  was  much 
degenerated  the  effects  of  the  digitalis  group 
were  very  temporary,  and  were  soon  followed 
by  a  period  of  depression  and  cardiac  ineffi- 
ciency. 


ACTION  OF  ADRENALIN  315 

Action  of  Adrenalin  on  the  Heart  and 
Vessels. — This  substance  when  injected  into 
the  circulation  causes  a  rise  of  blood-pressure, 
such  as  almost  no  other  substance,  except 
nicotine,  p.  323,  will  produce.32  This  is  due  to 
its  action  both  on  the  heart  and  vessels.  It 
appears  to  stimulate  the  post-ganglionic  terminal 
branches  of  sympathetic  nerves33  throughout 
the  whole  body,  dilating  the  pupil,34  increasing 
saliva  and  tears,35  contracting  the  uterus,36  but 
inhibiting  the  intestine,37  stomach,  bladder,  and 
sphincters 38  by  an  action  on  the  splanchnic39  It 
causes  contraction  of  all  the  arterioles  in  the 
body  40  with  the  exception  of  the  coronary  arteries, 
and  these  it  dilates.41  It  causes  the  heart  to  beat 
more  strongly  and  also  more  quickly,42  unless 
at  first,  when  the  rise  in  arterial  pressure  which 
it  produces  may  stimulate  the  vagus  roots  and 
thus  slow  the  pulse.43 

In  cases  of  shock  or  collapse  it  is  one  of  the 
most  powerful  remedies  we  possess  when  in- 
jected into  a  vein  or  even  subcutaneously ;  **  a 
disadvantage  it  possesses  is  that  its  action  is 
very  temporary.  This  may  possibly  be  con- 
nected with  a  curious  point  in  relation  to  its 
chemical  constitution  and  physiological  action. 
The  adrenalin  from  suprarenal  capsules  is 
laevo- rotary,  whilst  the  synthetic  adrenalin  con- 
sists of  an  admixture  of  two  kinds  of  adrenalin, 
one  of  which  is  laevo-  and  the  other  dextro-rotary. 
The  synthetic  Isevo-adrenalin  acts  like  that  from 
suprarenal  capsules.  The  dextro-adrenalin  has 
hardly  any  physiological  action,45  but  it  has  the 
power  of  preventing  the  action  of  laevo-adrenalin 


316          ACTION  OF  CARDIAC  TONICS 

when  subsequently  administered  even  in  large 
doses  ^  (cf.  Muscarine,  p.  280). 

When  given  by  the  mouth  adrenalin  is  com- 
paratively feeble. 

Camphor. — Camphor  is  an  exceedingly  power- 
ful stimulant  both  to  the  heart  and  to  the  vessels. 
When  applied  to  the  frog's  heart  it  increases  the 
frequency  and  power  of  its  contractions,47  and 
when  the  heart  has  been  brought  to  a  complete 
standstill  by  muscarine,  small  quantities  of 
camphor  added  to  the  nutrient  solution  will 
produce  occasional  pulsations.48  When  the 
heart  has  been  poisoned  by  chloral  and  is  beat- 
ing very  slowly  and  very  feebly,  camphor  in- 
creases both  the  frequency  and  power  of  the 
contractions.49  It  stimulates  the  vaso-motor 
centre  in  the  medulla  and  produces  contraction 
of  the  blood-vessels M  so  as  to  raise  the  blood- 
pressure,  even  when  it  has  been  greatly  lowered 
by  chloral.61 

The  most  remarkable  action  of  camphor, 
however,  is  its  power  to  stop  fibrillation  of  the 
heart  (p.  62)  when  excised,52  and  possibly  also 
when  in  the  body.58  It  was  at  one  time  very 
largely  used,  though  of  late  years  it  has  fallen 
out  of  fashion.  It  was  regarded  by  Pereira  as  a 
vascular  excitant.54 

Action  of  Strychnine  on  the  Heart. — Another 
drug  most  useful  in  cardiac  disease  is  strych- 
nine. Its  action  is  exerted  slightly,  if  at  all, 
upon  the  muscular  fibre,  but  it  greatly  increases 
the  reflex  excitability  of  nerve  centres.  This 
is  more  especially  marked  in  those  of  the  cord 
and  medulla,  such  as  the  vaso-motor  centre,  but 


CAMPHOR—  STRYCHNINE— CAFFEINE  317 

it  also  stimulates  peripheral  ganglia,  and  Cash 
and  I  found  that  when  applied  to  the  heart  it 
prevented  the  slowing  or  stoppage  of  the 
ventricle,  which  usually  occurs  from  the  applica- 
tion of  a  ligature  between  the  venous  sinus  and 
the  ventricle  (p.  269).56  In  some  books  on  Phar- 
macology the  action  of  strychnine  as  a  cardiac 
stimulant  is  to  a  great  extent  ignored ;  but  I  think 
that  in  medical  practice  the  use  of  this  drug  as  a 
cardiac  stimulant  has  of  late  years  become  more 
and  more  general,  and  it  is  justified  by  the  good 
effects  observed  from  it,  and  explained,  partly 
at  least,  by  the  action  on  the  heart  which  Cash 
and  I  found  it  to  have.  Under  its  use  we  fre- 
quently notice  that  a  pulse  which  was  previously 
feeble,  irregular,  or  intermittent,  becomes  steady, 
strong,  and  regular.  No  doubt  the  conditions 
which  regulate  the  pulse  are  very  complicated 
in  health,  and  still  more  in  disease,  so  that  it  is 
difficult  or  impossible  to  be  absolutely  certain  of 
the  exact  mode  of  action  of  strychnine ;  but  at 
the  same  time  its  good  effects  are,  I  think, 
undeniable,  and  the  explanation  that  I  have 
given  is  at  any  rate  feasible. 

Action  of  Caffeine  and  other  Purin  Bodies. 
— While  strychnine  exerts  its  beneficial  effect 
almost  entirely  through  the  nerves,  caffeine  and 
allied  bodies  probably  exert  it  more  especially 
through  their  stimulating  action  upon  the 
muscular  fibres  or  peripheral  nervous  system  of 
the  heart,56  and  upon  the  secreting  cells 57  in  the 
kidneys.  This  is  not  entirely  the  case,  however, 
for  all  the  plants  which  contain  either  caffeine 
or  theobromine  are  used  dietetically  as  stimu- 


318  ACTION  OF  CARDIAC  TONICS 

lants  to  the  nervous  system :  tea,  coffee,  and 
chocolate  being  the  most  commonly  employed, 
but  kola  and  guarana  being  also  largely  used  in 
Africa  and  South  America.  Like  digitalis, 
caffeine  stimulates  the  vaso-motor  centre  in  the 
medulla68  and  raises  the  blood-pressure  by 
causing  contraction  of  the  vessels.  This  rise  is 
sometimes  accompanied  by  a  slow  pulse,  as  in 
the  case  of  digitalis,  from  stimulation  of  the 
vagus  centre.59  Usually,  however,  it  goes  along 
with  an  acceleration  of  the  heart-beats.  The 
reason  of  this  probably  is  that  the  cardiac 
muscle  or  its  contained  nerves  are  rendered  by 
caffeine  more  irritable,60  and  the  coronary 
arteries  dilate,61  so  that  the  rhythmical  stimuli 
follow  one  another  more  quickly.  The  effect 
upon  the  kidneys  is  to  produce  a  considerably 
increased  flow  of  urine,  and  the  increase  of 
water  is  accompanied  also  by  an  increase  in  the 
solids,62  the  total  effect  being  chiefly  due  to 
stimulation  of  the  secreting  cells,  although  along 
with  this  there  is  dilatation  of  the  renal  vessels 
also.63  Theobromine  differs  from  caffeine  in 
having  much  less  effect  upon  the  vaso-motor 
centre  and  more  effect  upon  the  kidney  itself.64 
It  therefore  acts  more  powerfully  as  a  diuretic 
than  caffeine.  It  is  sparingly  soluble  in  water, 
but  is  rendered  more  soluble  by  trisodium 
phosphate,  and  several  synthetic  compounds 
have  been  introduced  into  medicine.  One  is 
called  diuretin,65  which  is  said  to  be  a  salicylate  of 
sodium  and  theobromine ;  agurin,  which  is  an 
acetate  of  sodium  and  theobromine ;  an  iodide 
of  sodium  and  theobromine ;  and  uropherin, 


PITUITARY  GLAND  319 

which  is  a  salicylate  of  lithium  and  theobromine. 
Synthetical  theophyllin  is  sold'  under  the  name 
theocine.  All  these  substances  are  useful  di- 
uretics, and  may  be  given  alone  or  in  combina- 
tion with  digitalis,  strophanthus,  or  drugs  having 
a  similar  action.  When  digitalis  or  other  sub- 
stances of  that  group  fail  to  act,  a  combination 
of  them  with  one  of  the  diuretics  group  may 
succeed. 

Pituitary  Gland. — An  extract  of  the  posterior 
part  of  the  gland  causes  vascular  contraction, 
rise  of  blood-pressure,  and  increased  power  of 
cardiac  contractions.  It  differs  from  adrenalin 
in  the  more  prolonged  rise  of  blood-pressure, 
and  in  slowing  the  heart  whether  the  vagus  is 
intact  or  divided,  thus  it  is  an  exceedingly  power- 
ful stimulant  in  depressed  circulatory  conditions, 
and  has  almost  miraculous  results  in  veronal 
poisoning  after  strychnine  has  failed.  It  dilates 
the  kidney  vessels  and  greatly  increases  the 
urine,  hence  it  is  useful  in  suppression  of  urine. 
If  a  second  dose  is  given  within  an  hour  or  two 
after  the  first,  its  effect  is  lessened  or  abolished, 
except  that  the  second  dose,  while  failing  to 
raise  the  blood-pressure,  still  increases  the  urine. 
This  diuretic  action  would  seem  to  be  partly 
due  to  a  specific  action  on  the  kidney  secretory 
cells.  It  also  causes  powerful  contraction  of  the 
uterus,  which  renders  it  of  service  in  post-partum 
haemorrhage,  and  of  the  intestine,  whence  it  may 
relieve  post-operative  intestinal  paralysis  and 
lessen  haemorrhage  in  typhoid  fever.  To  obtain 
a  rapid  action  in  the  cases  mentioned,  the  ex- 
tract should  be  injected  into  the  muscles,  and 


320  LITERATURE 

in  severe  shock  it  should  be  given  intravenously. 
In  chronic  cases  of  cardiac  debility  and  dilatation 
it  may  be  given  by  the  mouth.66 

LITERATURE. 

I  James  Blake,  Edin.  Med.  and  Surg,  Journ.,  1839,  voL 

li.,  p.  342. 

3  L.  Traube,  All.  med.  Centr.-Ztg.,  3Oth  Jahrg.,  1861  ; 

and  Gesammelte  Beitrdge,  1871,  vol.  i.,  p.  277. 
8  L.  Traube,  Centralb.  f.  d.  'med.  Wiss.,  p.  885,  1865. 

4  L.  Traube,  Berlin  klin.  Wochenschr.,  1871. 

6  Lauder   Brunton,    On  Digitalis,    1866 ;    reprinted    in 

Collected  Papers,  First  Series  (London  :  Macmillan 
&  Co.  Ltd.,  1907). 

8  Schmiedeberg,  Beitrdge  zur  Physiologic  Festschr.  fiir 
C.  Ludwig,  p.  224,  1874. 

7  Fagge  and  Stevenson,  Roy.  Soc.  Proc.,  1865,  vol.  xiv., 

P-  273- 

8  Pickering,  Journ.  of  Physiol.,  1893,  v°l-  ™v'>  P-  3^3- 

9  Pickering,  op.  cit.,  p.  436. 

10  Brunton  and  Cash,  St  Barth.  Hasp.  Rep.,  1882,  p.  267. 

II  K.  Hedbom,  Skand.  Arch.  f.  Physiol.,  vol.  viii.,  pp. 

147,  169  ;  Centralb.  f.  Physiol.,  1898,  Bd.  xii.,  p.  364. 

12  Brunton  and  Meyer,  Journ.  of  Anat.  and  Physiol.,  vol. 

vii.,  1873,  p.  134  ;  reprinted  Collected  Papers,  p.  141. 

13  Lauder  Brunton  and  Tunniclifte,  Journ.  of  Physiol., 

1896,  vol.  xx.,  p.  354. 

14  Brunton  and  Power,  Centralb.  f.  d.  med.  Wiss.,  1874, 

p.  497  ;  and  Proc.  Roy.  Soc.,  1874,  vol.  xxii.,  p.  420. 

16  Brunton  and  Pye,  Proc.  Roy.  Soc.,  1876,  vol.  xxv.,  p. 

172;  St  Bartholomew's  Hospital  Reports,  1876,  vol. 
xii.,  p.  125  ;  Phil.  Trans.,  1878,  vol.  clxvii.,  part  ii., 
p.  627. 
6  Loewi,  Wiener  klin.  Wochenschr.,  1907. 

17  Brunton  and  Power,  op.  cit. 

18  Brunton  and  Pye,  op.  cit. 

19  Lauder  Brunton  on  "  Digitalis,"  Collected  Papers,  p. 

83  (Macmillan  &  Co. :  London,  1906). 

20  Ackermann,  Deutsch.  Arch.  f.  klin,  Med.,   1873,   v°l- 

xi.,  p.  125  ;  Kochmann,  Arch,  de  Pharmacodynamie 
etde  Therap.,  1905,  vol.  xvi.,  p.  221  et  seq. 


LITERATURE  OF  CHAPTER  X!f        321 

21  Braun  and  Mager,  Sitzungsb.  d.  Wiener  Akad.,  1899, 

vol.  cviii.,  p.  741  et  seq. 

22  Gottlieb,  Meyer  and  Gottlieb's  Phannakologie,  p.  224. 

23  Gottlieb  and  Magnus,  Arch.  /.  exp.  Path.  u.  Pharm., 

1904,  vol.  li.,  p.  63. 

24  Lauder  Brunton   on  "Digitalis,"  Notes  of  i7th   and 

igth    March   1865,  Collected  Papers  on  Circulation 
and  Respiration,  p.  83. 

26  Ranvier,  Compt.  rend.,  1869,  vol.  Ixix.,  p.  1326;  Hehn, 
Centralb.  /.  d.  med.  Wiss.,  1873,  P-  625  ;  Janowski, 
1883,  Virch.  Arch.,  vol.  xciii.,  p.  259. 

26  For  the  action  and  literature  of  most  of  these,  vide 

Schmiedeberg,  Arch.f.  exp.  Path.  u.  Pharm.,  1883, 
vol.  xvi.,  p.  149  et  seq. 

27  Brunton,  op.  cit. 

28  T.  R.  Eraser,  Journ.  of  Anat.  and  Physiol.,  1885,  vol. 

vii.,  p.  154. 

29  Brunton  and  Pye,  op.  cit. 

30  Brunton  on  "  Digitalis,"  etc.,  1868  (London  :  Churchill), 

p.  58;  and  Collected  Reprints,  First  Series,  1907,  p.  77. 

31  Scalfati,  Rif.  med.,  6th  April  1911  ;  abstracted  in  the 

Brit.  Med.  Journ.  Epitome,  I4th  Sept.  1912,  p.  36. 

32  Oliver  and  Schafer,  Journ.  of  Physiol.,  1895,  vol.  xviii. ; 

p.  239,  giving  earlier  literature. 

33  Langley,  Journ.  of  Physiol.,  1901-2,  vol.  xxvii.,  p.  256, 

and   1905-6,   vol.  xxxiii.,  p.  405  ;  Elliot,  ibid,  1905. 
vol.  xxxii.,  p.  429. 

34  Lewandowsky,  Arch.f.  Anat.u.  Physiol.,  rSog,  p.  360  : 

Boruttau,  Pfluger's  Arch.,  1899,  vol.  Ixxviii.,  p.  112 
Langley,  Journ.  Physiol ,  vol.  xxvii.,  p.  244. 

35  Langley,  op  cit.,  vol.  xxvii.,  pp.  238  and  247. 

36  Langley,  op.  cit.,  vol.  xxvii.,  p.  252. 

37  Boruttau,  Pfliiger's  Arch.,  1899,  vol.  Ixxviii.,  p.   113; 

Langley,  op.  cit.,  vol.  xxvii.,  p.  249. 

38  Langley,  op.  cit.,  vol.  xxvii.,  p.  255. 

39  Pfliiger,  Ueber  d.  Hemmungsnervensystem  f.  d.  peris 

taltische  Bewegungen  d.  Gedarme  (Berlin,  1857). 

40  Oliver  and  Schafer,  op.  cit.,  vol.  xviii.,  p.  239. 

41  Douglas  Cow,  Journ.  of  Physiol.,  1911,  vol.  xlii.,  p.  132. 

42  Gottlieb,  Arch.  f.  exp.  Path.  u.  Pharm.,    1897,  vol 

xxxviii.,  p.  99  ;  and  1899,  vol.  xliii.,  p.  286. 

43  Oliver  and  Schafer,  op.  cit.,  vol.  xviii.,  p.  247. 


322  LITERATURE 

44  Crile,  Blood  Pressure  in  Surgery,  pp.  412   and  413 
(Philadelphia  and  London  :  Lippincott  Co.,  1903). 

46  Cushny,  Journ.  of  Physiol.,  1908,  vol.  xxxvii.,  p.  130 

et  seq. 
48  Frohlich,  Centralb.f.  Physiol.,  1909,  vol.  xxiii.,  p.  254. 

47  Heubner,  Arch.f.  Heilk.,  1870,  vol.  ix.,  p.  334  ;  Baum, 

Centralb,  f.  d.  med.  Wiss.,  1870,  vol.  viii.,  p.  467. 

48  Harnack  and  Witkowski,  Arch.f.  exp.  Path.  u.  Pharm.t 

1876,  vol.  v.,  p.  429  ;  Wiedemann,  ibid.,  1877,  vol.  vi., 

p.  222. 

4<  Gottlieb,  Meyer  and  Gottlieb,  Pharmakologie,  p.  216. 

50  Wiedemann,  Arch.f.  exp.  Path.  u.  Pharm.,  1877,  v°l- 

vi.,  p.  227. 

51  Alexander- Lewin,     ibid.,    1890,    vol.    xxvii.,   p.    231  ; 

Bohme,  ibid.,  1905,  vol.  Hi.,  p.  346  et  seq. 

52  Seligmann,  Arch.  f.  exp.  Path.  u.  Pharm.,  1905,  vol. 

lii.,  p.  341. 

53  Seligmann,  op.  cit.,  p.  345. 

54  Pereira,  Elements  of  MateriaMedica  and  Therapeutics, 

4th  ed.,  vol.  ii.,  part  i.,  p.  454  (London  :  1855). 
"  Brunton  and  Cash,  "On  the  Explanation  of  Stannius's 
Experiment,  and  on  the  Action  of  Strychnia  on  the 
Heart,"  St  Bartholomew's  Hospital  Reports,  vol.  xvi., 
1880 ;  in  Collected  Papers,  p.  557  ;  cf.  p.  558. 

56  Dreser,  Arch.  f.  exp.  Path.  u.  Pharm.,  1888,  vol.  xxiv., 

p.  240 ;  Bock,  ibid.,  1900,  vol.  xliii.,  pp.  387  and  398. 

57  von  Schrpeder,  Arch.  f.  exp.  Path.  u.  Pharm.,  1897, 

vol.  xxii.,  p.  57. 
68  Bock,  op.  cit.,  pp.  390  and  399. 

49  Bock,  op.  cit.,  p.  398. 
60  Bock,  op.  cit.,  p.  398. 

51  Hedbom,  quoted  by  Bock,  op.  cit.,  pp.  368  and  392. 
82  von  Schroeder,  op.  cit.,  vol.  xxii.,  p.  47. 

63  Loewi,  IVien.  klin.  Wochensch.,  1907,  No.  i. 

64  von  Schroeder,  op.  cit.,  vol.  xxiv.,  p.  101. 

65  Hoffmann,  Arch.  f.  exp.  Path.  u.  Pharm.,  1891,  vol. 

xxviii.,  p.  i  et  seq. 

66  Schafer,    Pharmaceutical  Journ.,     1907,    vol.    Ixxix., 

p.  670 ;  ibid.,  Roy.  Soc.  Proc.,  1909,  B,  vol.  Ixxxi. 


CHAPTER   XIII 

ACTION   OF  CARDIAC  DEPRESSANTS 

Nicotine — Tobacco-Smoking  —  Effects  of  Smoking  — 
Attractions  of  Smoking  —  Excessive  Smoking  — 
Aconite. 

Nicotine. — Another  drug  which  has  a  very 
powerful  influence  upon  the  blood-pressure  and 
cardiac  action  is  nicotine.  Both  in  frogs  and 
mammals  nicotine  produces,  first  convulsions  and 
then  paralysis.1  When  applied  in  small  doses 
to  the  frog's  heart,  it  causes  the  beats  at  first 
to  become  slow  and  afterwards  quick.2  If  the 
dose  be  large,  no  primary  slowing  may  be 
observed.  In  animals  it  causes  slowing  of 
the  heart,  with  enormous  rise  of  blood-pressure.3 
The  rise  of  blood-pressure  is  so  great  that  I 
have  never  seen  it  equalled  after  the  injection 
of  any  drug,  with  the  exception  of  suprarenal 
extract.  The  rise  of  pressure  is  chiefly 
due  to  contraction  of  the  arterioles.  This 
contraction  is  partly  dependent  upon  stimula- 
tion of  the  vaso-motor  centre  in  the  medulla 
oblongata,  but  partly  also  to  a  local  action 
upon  the  arterioles  themselves,  as  it  may  be 
produced  by  injection  of  the  drug  even  after 


324  ACTION  OF  CARDIAC  DEPRESSANTS 

the  medulla  has  been  destroyed.  The  pulse- 
rate  in  mammals  is  first  slowed  and  afterwards 
quickened,  just  as  in  the  frog.  The  slowing  is 
due  partly  to  stimulation  of  the  vagus  centre 
in  the  medulla  oblongata,  and  partly  to  the 
stimulation  of  the  inhibitory  apparatus  in  the 
heart  itself.  The  subsequent  increase  in  the 
pulse-rate  is  due  to  paralysis  of  these  ganglia. 
In  consequence  of  this  double  action  of  nicotine, 
if  the  vagus  be  divided  during  the  period  of 
slow  pulse,  the  pulse  becomes  somewhat 
quicker,  but  still  remains  slower  than  normal. 
When,  however,  the  dose  has  been  sufficiently 
large  to  quicken  the  pulse,  no  stimulation  of 
the  vagus  will  slow  the  heart,  as  its  terminal 
branches  in  the  heart  are  paralysed  by  the 
drug.5  This  action  is  the  same  in  the  heart 
of  the  frog,  so  that  after  a  large  dose  of 
nicotine,  stimulation  of  the  vagus  has  no 
effect  upon  the  heart,  but  stimulation  of  the 
venous  sinus  itself  will  slow  the  heart.6  The 
reason  of  this  probably  is,  that  although  the 
inhibitory  ganglia  in  the  heart  are  paralysed, 
the  inhibitory  neurons  which  proceed  from 
them  are  still  intact,  and  are  affected  by  local 
stimulation.7 

Formerly  tobacco  enemata  were  used  as  a 
means  of  causing  vascular  and  general  relaxa- 
tion, but  they  were  far  from  being  without 
danger  and  are  never  employed  now.8  But 
although  tobacco  is  not  used  as  a  remedy  for 
disease,  its  employment  is  so  universal  that 
its  action  requires  very  careful  consideration. 
Nicotine  alone  is  only  taken  into  the  body 


TOBACCO-SMOKING  325 

when  tobacco  is  used  by  chewing  or  by  snuff- 
ing. When  it  is  chewed,  most  of  the  juice  is 
expectorated,  but  a  small  portion  is  probably 
swallowed.  When  tobacco  is  used  in  the  form 
of  snuff,  small  quantities  of  it  find  their  way 
into  the  naso-pharynx  and  they  are  swallowed. 
The  tobacco  used  for  chewing  or  snuffing 
contains,  as  a  rule,  but  very  little  nicotine, 
and  so  symptoms  of  poisoning  from  either  of 
those  habits  are  rare. 

Tobacco-smoking. — Usually  tobacco  is  em- 
ployed by  smoking,  either  in  the  form  of  cigars 
or  cigarettes,  or  in  a  pipe.  When  used  in  any 
one  of  these  forms  it  is  not  pure  nicotine  which 
reaches  the  mouth,  but  really  the  products 
of  the  dry  distillation  of  tobacco,  containing  a 
large  quantity  of  pyridine  and  picoline  bases. 
Probably  nicotine  in  greater  or  less  quantity 
is  also  present.9  The  proportions  of  the 
pyridine  and  picoline  bases  in  the  tobacco- 
smoke  vary  according  to  the  mode  in  which 
it  is  burnt.  In  a  cigar  there  is  a  freer  access 
of  air,  so  that  much  collidine  and  little  pyridine 
are  formed,  while  in  a  pipe  much  more  pyridine 
is  produced,  and  thus  stronger  tobacco  can  be 
smoked  in  a  cigar  than  in  a  pipe.  So  much 
is  this  the  case,  that  tobacco  which  in  the 
form  of  a  cigar  would  produce  no  disagreeable 
effect  may  cause  giddiness  and  vomiting  if 
smoked  in  a  pipe.10  The  smoke  from  a  pipe 
or  cigar  usually  passes  simply  into  the  mouth 
and  out  again,  either  through  the  mouth  or 
the  nostrils ;  but  when  smoked  in  a  huka  or 
narghileh,  the  smoke  is  inhaled  into  the  lungs, 


326   ACTION  OF  CARDIAC  DEPRESSANTS 

and  this  is  frequently  done  also  by  people  who 
smoke  cigarettes.  When  a  huka  or  a  narghileh 
is  used,  the  smoke  passes  through  water  before 
being  inhaled,  and  it  is  thus  deprived  of  most 
of  its  poisonous  constituents ;  but  this  is  not 
so  with  the  smoke  of  cigarettes,  and  as  absorp- 
tion occurs  very  rapidly  from  the  pulmonary 
mucous  membrane,  cigarette-smoking  is  some- 
times very  injurious.  There  is  another  reason, 
however,  why  cigarette-smoking  is  frequently 
more  harmful  than  smoking  a  pipe  or  cigar, 
and  it  is  that  cigarettes  are  small  and  can  be 
smoked  in  a  few  minutes,  so  that  many  more 
cigarettes  than  pipes  or  cigars  are  consumed 
in  the  course  of  the  day,  and  the  total  quantity 
of  tobacco  used  is  thus  much  greater  in  the 
form  of  cigarettes. 

Smoking  in  moderation  does  not  seem  to  be 
injurious  to  grown-up  people,  but  there  appears 
to  be  a  general  consensus  of  opinion  that  it  is 
very  distinctly  harmful  to  growing  lads. 

Attractions  of  Smoking. — In  adults,  smoking 
appears  to  have  a  double  action.  It  will  stimu- 
late the  brain  to  increased  activity,  and  it  will 
also  produce  a  soothing  effect  in  conditions  of 
excitement.  Its  stimulating  effect  upon  mental 
activity  is  probably  partly  due  to  the  local 
irritant  action  of  smoke  upon  the  mouth,  causing 
reflex  dilation  of  the  vessels  which  supply  the 
brain  in  somewhat  the  same  way  as  mastication.11 
Its  action  as  a  sedative  is  probably  partly  due 
to  the  necessity  of  breathing  rhythmically  while 
smoking,  and  the  soothing  effect  of  watching 
the  smoke  as  it  issues  from  the  lips  or  nostrils, 


RESULTS  OF  EXCESSIVE  SMOKING    327 

especially  when  it  is  blown  out  in  the  form  of 
rings.  This  is  by  no  means  an  unimportant 
factor,  for  many  people  derive  but  very  little 
pleasure  from  smoking  in  the  dark. 

Results  of  Excessive  Smoking. — One  of  the 
commonest  results  of  excessive  smoking  is 
chronic  pharyngitis,  with  irritability  of  the 
throat,  cough  and  hoarseness,  and  sometimes 
the  irritation  also  affects  the  tongue.  Weakness 
of  vision,  nervous  tremor,  and  giddiness  fre- 
quently result  from  tobacco-smoking.  It  is 
difficult  to  decide  how  far  these  are  due  to  the 
direct  action  of  the  tobacco-smoke  upon  the 
nervous  system  and  how  far  they  are  caused 
through  alteration  in  the  circulation.  The 
circulation  becomes  much  affected ;  palpitation 
and  pain  in  the  cardiac  region  are  common 
results.  Sometimes,  though  rarely,  the  cardiac 
pain  may  be  so  great  as  to  simulate  angina 
pectoris.  Irregularity  of  the  heart  is  very 
common,  and  it  appears  to  me  that  this  irregu- 
larity is  more  frequently  found  from  a  common 
kind  of  tobacco  known  as  "  pigtail "  than  from 
better-class  tobaccos.  When  I  was  a  house 
physician  I  met  with  it  very  frequently,  and  the 
cardiac  rhythm  might  be  represented  somewhat 


in   this  way  : 


a    pause, 


followed  by  one  or  two  heavy  beats,  then  a 
succession  of  quick,  small  beats,  and  then  a 
pause  again.  With  better-class  tobaccos  I  have 
not  observed  this  irregularity  so  frequently,  but 
I  have  more  often  seen  the  patient  simply  fall 


328  ACTION  OF  CARDIAC  DEPRESSANTS 

down  unconscious,  as  if  he  had  been  shot. 
These  unpleasant  symptoms,  as  well  as  the 
nervous  symptoms  which  accompany  them,  may 
sometimes  cease  upon  lessening  the  amount  of 
tobacco  used,  but  not  unfrequently  a  very  small 
quantity  appears  to  keep  up  the  condition  after 
it  has  once  been  established ;  and  complete 
abstinence  from  tobacco,  occasionally  for  a 
period  of  several  months,  is  required  before  it 
can  be  resumed  without  causing  a  recurrence  of 
the  symptoms.  I  have  found  that  a  very  low 
arterial  tension,  90  to  1 10,  or  even  lower  in 
persons  otherwise  healthy,  is  frequently  an 
indication  of  excessive  smoking,  cf.  p.  181. 

Aconite. — Aconite  12  is  a  drug  which  may  be 
looked  upon  as  a  typical  cardiac  depressant. 
Its  most  characteristic  physiological  action  is 
that  of  causing  numbness  and  tingling  when 
applied  to  the  tongue  in  small  quantities,  and 
this  test  is  much  more  delicate  than  any 
chemical  reaction.  When  administered  to 
mammals  in  small  doses  it  slows  the  heart 
very  greatly,  and  this  effect  is  entirely  due  to 
its  action  upon  the  vagus  centre.  Its  effects 
are  precisely  similar  to  those  produced  by 
stimulation  of  the  vagus,  the  heart  being 
rendered  slow  and  the  blood-pressure  failing. 
In  larger  doses  it  paralyses  the  ends  of  the 
vagus  in  the  heart,  so  that  the  pulse  becomes 
suddenly  very  rapid  and  at  the  same  time  very 
irregular,  while  the  blood-pressure  oscillates  in  a 
remarkable  manner.13  It  appears  to  have  also 
a  local  action  on  the  cardiac  muscle,  but  this  is 
of  a  very  complex  nature,14  and,  I  think,  is 


ACONITE  329 

probably  connected  with  stimulation  and  par- 
alysis of  some  sensory  mechanism  in  the  heart 
itself,  to  which  the  cardiac  pulsations  are  partly 
due.  That  such  a  reflex  mechanism  actually 
exists  in  the  heart  itself  appears  to  be  shown, 
amongst  other  things,  by  the  experiments  of 
von  Basch  and  A.  Frohlich 15  upon  the  action  of 
cocaine  on  the  heart.  They  found  that  when 
the  surface  of  the  heart  was  stimulated  by  a 
faradic  current,  which  caused  an  extra  beat 
and  compensatory  pause,  this  effect  diminished 
rapidly  when  cocaine  was  applied  to  the  surface 
of  the  heart  This  action  was  not  due  to  any 
effect  of  cocaine  upon  the  cardiac  muscle,  but 
only  to  its  local  action  on  the  epicardium.  It  is 
not  improbable  that  the  effect  of  aconite  upon 
the  heart  may  be  due  to  an  action  upon  the 
sensory  mechanism  in  it  somewhat  analogous 
to  that  of  cocaine.  One  effect  of  aconite  is  to 
disturb  the  rhythm  very  greatly,  so  that  in  the 
frog's  heart  the  normal  beats  and  peristaltic 
action  may  alternate. 

The  chief  use  of  aconite  is  in  local  in- 
flammations accompanied  by  general  febrile 
disturbance.  Small  doses  of  this  drug  appear 
occasionally  to  be  exceedingly  useful,  for 
example,  in  tonsillitis  and  in  febrile  colds.16 
In  nervous  flutterings  of  the  heart,  aconite  in 
small  doses  appears  to  quiet  the  circulation,  but 
how  it  does  so  I  cannot  at  present  explain. 
Very  small  doses  are  sufficient,  and  often  seem 
to  slow  the  pulse  more  than  larger  ones. 
One  minim  of  the  pharmacopceial  tincture 
every  hour  is  frequently  sufficient,  although 

Z 


330  LITERATURE 

the  dose  given  in  the  British  Pharmacopoeia  is 
2  to  5  minims,  frequently  repeated,  or  5  to  15 
minims  when  given  at  longer  intervals.  In 
cases  of  persistent  high  tension  with  attacks 
of  angina  pectoris,  aconite  is  sometimes  useful. 
Its  action  should  be  regulated  by  a  sphygmo- 
manometer. 


LITERATURE. 

1  Van  Praag,  Virchoitfs  Archiv,  vol.  viii.,  p.  56  ;  Wachen- 

feld,  quoted  by  Husemann,  Pflanzensfoffe,  2nd  ed., 
p.  1 174  (Berlin:  Springer,  1882). 

2  Schmiedeberg,  Sitzungsb.  d.  k.  sacks.  Gesellsch.  d.  Wiss.^ 

1870,  p.  130  et  seq.;  and  Ludwig's  Arbeiten,  1870, 
p.  41  et  seq. 

3  L.  Traube,  All.  med.  Centr.-,  1862  ;  and  Gesam.  Beitraget 

1871,  vol.   i.,   p.   302   (Berlin :    Hirschwald).      For 
other  literature,  see  Kobert,  Lehrb.  d.  Intoxikationen, 
2nd  ed.,  Bd.  ii.,  p.  1069  (Stuttgart :  Enke,  1906). 

4  Rosenthal,  Centralb.f.  d.  med.  Wiss.^  1863,  p.  736. 
6  Rosenthal,  op.  cit. 

6  Schmiedeberg,  op.  cit. 

7  Langley  and  Dickinson,  Journ   of  Physiol.,  1890,  vol. 

xi.,  p.  265. 

8  Pereira,  Materia  Medtca,  vol.  ii.,  part  i.,  p.  583,  4th  ed. 

(London  :  Longmans,  1855). 

9  See  literature  in   Kunkel's  Handb.  d.   Toxicologie,  p. 

681  (Jena:  Fischer,  1901). 

10  Vohl  and  Eulenburg,  Arch.  Pharm.,  vol.  ii.,  part  cxlvii., 

pp.  130-166  ;  abstracted  by  Lauder  B  run  ton  in  Journ. 
Chem.  Soc.,  1871,  New  Series,  vol.  ix.,  p.  1075. 

11  Marey,  Circul.  du  Sang,  p.  319  (Paris  :  Masson,  1881). 

12  For  literature,  vide  Husemann,  Pflanzensloffe^  2nd  ed., 

vol.  i.,  p.  624  (Berlin  :  Springer,  1882) ;  and  Kobert, 
Lehrb.  d.  Intoxikationen^  2nd  ed..  Bd.  ii.,  p.  114? 
(Stuttgart:  Enke,  1906). 

13  Cash  and  Dunstan,  Roy.  Soc.  Proc.,  1898,   «rol.  Ixii., 


LITERATURE  OF  CHAPTER  X1IL        331 

p.  341  ;  vide  also,  Roy.  Soc.  Proc.,  1901,  vol.  Ixviii., 
pp.  378  and  384. 

14  Schmiedeberg,   Grundriss    d.    Pharmakologie,  p.   163 

(Leipzig :  Vogel,  1902). 

15  von    Basch    and  A.    Frohlich,    Centralb.   f.   Phystol., 

Bd.  xviii.,  Literatur,  1904,  p.  693. 

16  Ringer  and  Sainsbury,  Handbook  of  Therapeutics,  1 3th 

ed.,  p.  470  (London  :  Lewis,  1897). 


CHAPTER  XIV 

ACTION   OF   DRUGS  ON    BLOOD-VESSELS 

Drugs  acting  on  the  Blood-vessels — Vaso-motor  Con- 
tractors— Peripheral  and  Central — Vaso-dilators — 
History  of  their  Discovery — Classes  of  Vaso-dilators 
—  Iodides  —  Effect  of  Drugs  upon  the  Coronary 
Arteries. 

Action  of  Drugs  upon  the  Blood-vessels. — 
The  blood  -  vessels  may  be  either  dilated  or 
contracted  by  the  action  of  drugs,  and  these 
effects  may  be  produced  either  by  central  or 
peripheral  action.  These  actions  may  either 
aid  one  another,  as  in  the  case  of  nitrite  of 
amyl  already  cited,  or  may  tend  to  counteract 
one  another.  I  have  already  mentioned  that 
the  vaso- motor  centre  has  the  function  of 
regulating  the  distribution  of  blood  in  the  body, 
so  that  when  the  vessels  in  one  district  are 
dilated,  those  in  another  are  contracted.  Thus 
very  great  variations  may  occur  in  the  local 
distribution  of  blood  without  any  alteration  in 
the  general  blood-pressure,  although  when  many 
vessels  contract  at  the  same  time  the  pressure 
will  rise,  and  when  many  are  dilated  the  pressure 
will  fall.  The  selective  action  of  drugs  is  very 
well  marked  in  regard  to  the  blood-vessels,  so 

882 


VASO-MOTOR  CONTRACTORS  333 

that  not  only  may  the  vessels  which  supply  one 
vascular  area  be  contracted  while  others  are 
dilated  by  a  certain  drug,  but  the  same  parts 
of  the  vessel  in  one  vascular  area  may  be 
contracted  while  others  are  dilated.  As  the 
splanchnic  area  is  the  most  powerful  in  regulat- 
ing blood-pressure  (p.  19),  one  would  naturally 
expect  that  its  vessels  would  react  more  quickly 
to  drugs  than  those  of  other  parts,  and  accord- 
ingly it  has  been  found  that  whilst  adrenalin 
causes  very  marked  contraction  in  the  splanchnic 
arteries  it  has  less  action  upon  those  of  the  legs, 
and  produces  dilatation  instead  of  contraction 
in  the  coronary  arteries.1  Whilst  the  splanchnic 
vessels  are  contracted  on  the  whole  by  adrenalin 
it  does  not  act  equally  upon  the  whole  of  them 
because  some  parts  may  be  actually  dilated  by 
it  while  other  parts  are  contracted  (cf.  p.  315). 

Vaso-motor  Contractors.  Peripheral.  —  As 
the  local  contraction  of  vessels  is  the  means  by 
which  the  supply  of  nutriment  and  oxygen  to 
the  tissues  is  regulated,  the  amount  of  oxygen 
contained  in  the  blood  has  a  powerful  action  on 
the  size  of  the  vessels.  As  Ludwig 2  has  pointed 
out,  when  the  blood  supplied  to  an  isolated 
organ  is  richly  arterialised,  the  vessels  contract, 
and  the  circulation  through  it  becomes  lessened. 
If  the  supply  of  blood  be  stopped  so  that  the 
tissues  become,  as  it  were,  asphyxiated,  the 
vessels  dilate  and  the  circulation  becomes 
exceedingly  rapid  when  it  is  again  re-estab- 
lished ;  just  as  when  a  man  ceases  to  breathe  for 
a.  few  moments  he  is  obliged  to  take  several 
deep  breaths  immediately  afterwards. 


334    ACTION  OF  DRUGS  ON  BLOOD-VESSELS 

Reaction  of  the  circulating  fluid  is  of  great 
importance,  as  acids  tend  to  cause  dilatation 
and  alkalies  contraction.3  The  effect  of  alkaline 
bases  on  the  vessels  is  not  always  the  same  as 
upon  the  heart,  for  potash  salts,  as  already 
mentioned,  tend  to  cause  enfeeblement  of  the 
heart  with  stoppage  in  diastole,  while  they  have 
an  opposite  effect  on  the  vessels,  in  which  they 
tend  to  cause  contraction  instead  of  dilatation. 
The  action  of  barium,  however,  on  the  muscular 
substance  of  the  heart  and  vessels  is  alike,  for  in 
both  it  tends  to  cause  prolonged  contraction.4 

One  of  the  most  powerful  vaso-constrictants 
is  adrenalin.  It  has  the  power  of  contracting 
all  the  vessels  in  the  body  with  the  exception  of 
the  intrapulmonary  portion  of  the  pulmonary 
artery,  the  coronary,  and  the  cerebral  arteries. 
In  the  two  last  it  causes  dilatation.6 

Cocaine  possesses  the  power  of  contracting  the 
vessels  in  addition  to  its  local  anaesthetic  action. 
A  combination  of  adrenalin  with  cocaine  forms 
a  very  powerful  local  anaesthetic,  as  the  con- 
stricting action  of  the  two  drugs  greatly  lessens 
the  local  circulation,  and  thus  prevents  cocaine 
from  being  carried  away  and  allows  it  to  exer- 
cise prolonged  anaesthetic  action. 

Pituitary  extract  has  an  action  somewhat 
similar  to  that  of  adrenalin,  but  it  is  not  so 
powerful  nor  so  prolonged,  and  less  certain, 
sometimes  causing  dilatation  instead  of  contrac- 
tion.6 All  substances  belonging  to  the  digitalis 
group  have  a  certain  power  of  contracting  the 
vessels  locally.  With  small  doses  the  contrac- 
tion is  limited  to  the  intestinal  vessels,  while 


VASO-D1LATORS  335 

the  renal  vessels  become  dilated  ;  with  larger 
doses  the  renal  vessels  also  become  contracted.7 

Central. — All  drugs  which  in  large  quantities 
have  a  convulsant  action,  such  as  strychnine  and 
pikrotoxin,  stimulate  the  vaso-motor  centre,  and 
those  tend  to  cause  contraction  of  the  blood- 
vessels and  raise  the  blood-pressure.  All  the 
vessels  of  the  body  are  not  equally  affected  by 
strychnine.  Those  of  the  splanchnic  area  are 
affected  more  than  the  others,  but,  unlike  digi- 
talis, which  tends  to  dilate  the  vessels  of  the 
kidney,  strychnine  causes  them  to  contract.8 

Caffeine  has  an  action  upon  the  vaso-motor 
centre  similar  to  that  of  strychnine,  but  it  acts 
locally  on  the  periphery  vessels  in  exactly  a 
contrary  manner,  tending  to  dilate  them.  Cam- 
phor also  stimulates  the  vaso-motor  centre  and 
renders  it  more  sensitive  to  reflex  stimuli,  while 
the  vessels  of  the  splanchnic  area  are  contracted 
by  it.  The  vessels  of  the  skin  are  dilated. 

Alcohol  produces  dilatation  of  the  peripheral 
vessels,  and  tends  to  lower  the  blood-pressure, 
while  at  the  same  time  it  stimulates  the  heart.9 

Vaso-dilators.  History  of  their  Discovery. — 
The  first  vaso-dilator  investigated  was  nitrite  of 
amyl.  Its  power  of  causing  flushing  of  the  face 
was  noticed  by  Guthrie  in  i859,10  and  Dr  B.  W. 
Richardson  observed  that  it  caused  dilatation 
of  the  capillaries  in  the  frog's  foot ;  but  it  was 
Dr  Arthur  Gamgee  who  first  discovered  its 
power  of  lowering  the  blood-pressure.  It  was 
under  his  direction  that  I  had  been  carrying 
out  my  experiments  on  digitalis  in  the  late 
Professor  Douglas  Maclagan's  laboratory,  and 


336   ACTION  OF  DRUGS  ON  BLOOD-VESSELS 

I  used  to  submit  myself  to  Dr  Gamgee  for 
experiments  upon  the  effect  of  nitrite  of 
amyl  on  my  own  pulse,  from  which  he  made 
sphygmographic  tracings.  These  experiments 
naturally  rendered  me  thoroughly  conversant 
with  its  physiological  action  on  the  pulse.  The 
numerous  observations  I  had  made  upon  my  own 
pulse  naturally  made  me  rather  expert  in  the 
use  of  the  sphygmograph ;  and  when  resident 
in  the  Royal  Infirmary  at  Edinburgh  I  made  a 
number  of  observations  upon  a  case  of  angina 
pectoris  which  was  at  that  time  in  the  wards.  I 
found  that  during  every  attack  the  tension  of 
the  pulse  became  greatly  increased,  and  as  the 
pain  passed  off  the  tension  fell.  Every  remedy 
had  been  tried  in  vain,  and  the  patient  was  just 
going  out  of  the  hospital  when  it  occurred  to  me 
that  if  one  could  lower  the  pressure  in  his  vessels 
one  would  very  probably  relieve  his  pain.  I 
therefore  kept  him  in  one  day  longer  to  try  the 
experiment,  and  promised  him  that  if  it  should 
fail  he  should  go  out  next  day.  To  my  delight 
the  experiment  proved  a  complete  success.  As 
I  administered  the  nitrite  of  amyl,  which  my 
friend  Dr  Gamgee  had  given  me,  the  patient's 
face  became  flushed,  the  pulse,  instead  of  being 
small  and  thready,  became  full  and  bounding,  and 
the  pain  almost  instantaneously  disappeared.11 
Nitrite  of  amyl  still  holds  its  place  in  medical 
practice  as  the  most  rapid  and  powerful  vascular 
dilator,  but  other  nitrites  or  nitrates  having  a 
slower  but  more  lasting  action  have  now  come 
into  more  general  use.  In  1876,  along  with  Mr 
Tait,12  I  discovered  that  nitroglycerine  had  an 


AMYL  NITRITE 


337 


FIG.  100. — Tracing  showing  the  action  of  amy  1  nitrite  on  the  blood-pressure. 
The  point  where  the  administration  was  begun  is  marked  by  a  cross  ; 
the  point  where  it  was  discontinued,  by  a  small  arrow.  The  hori- 
zontal double-headed  arrow  indicates  the  zero  point  of  pressure ;  the 
single-headed  arrow  indicates  the  direction  in  which  the  tracing  is  to 
,  be  read. 


338    ACTION  OF  DRUGS  ON  BLOOD-VESSELS 

action  upon  the  circulation  similar  to  that  of 
nitrite  of  amyl,  but  I  used  to  get  such  an  awful 
headache  from  working  with  it  that  I  hesitated 
to  give  it  to  patients,  and  while  I  was  still 
hesitating  Dr  Murrell  employed  it  in  a  case  of 
angina  with  great  success.13  It  has  now  become 
the  stock  remedy  for  lowering  arterial  tension, 
and  has  been  introduced  into  the  British  Phar- 
macopoeia in  the  form  of  tablets  containing  a 
hundredth  of  a  grain  in  chocolate.  These  may 
be  either  taken  at  once,  or  a  little  bit  of  them 
may  be  nibbled,  and  the  nibbling  carried  on 
until  the  pain  passes  off.  If  one  is  not  sufficient, 
more  may  be  used.  Whilst  working  in  Professor 
Ludwig's  laboratory  in  1869, 1  found  that  sodium 
nitrite  had  a  similar  action  to  amyl  nitrite,  but 
not  so  marked.  This  observation  was  not 
published,  and  the  action  of  sodium  nitrite  was 
described  some  years  later  by  Prof.  M.  Hay.14  In 
1876  and  1877  I  made  also  a  large  number  of 
experiments,  along  with  the  late  Dr  Gresswell 
of  Melbourne,  on  the  action  of  other  nitrites, 
but  owing  to  various  circumstances  these  results 
also  have  not  been  published.  A  very  interest- 
ing research  by  Professors  Cash  and  Dunstan 15 
on  various  nitrites  shows  that  they  are  all  alike 
in  the  nature  of  their  action,  though  differing 
somewhat  in  degree.  The  same  is  the  case  with 
a  substance  differing  entirely  from  them  chemi- 
cally, namely,  hydroxylamine,  which  Mr  T.  J. 
Bokenham  and  I  found  to  dilate  the  vessels,  and 
produce  a  fall  in  the  blood  -  pressure  almost 
identical  with  that  caused  by  nitrate  of  amyl.16 
A  most  interesting  discussion  of  the  drugs 


CLASSES  OF  VASO-DILATORS          339 

belonging  to  the  nitrous  group  is  contained  in 
the  lectures  of  the  late  Professor  Leech,17  whose 
death  was  a  loss  to  the  whole  scientific  world, 
and  a  great  personal  grief  to  everyone  who 
knew  him.  Nitroerythrol  is  another  substance 
which  is  almost  more  useful  than  any  of  the 
other  nitrites,  because  its  action,  though  less 
powerful,  is  more  prolonged  than  theirs,  and  in 
cases  where  we  wish  to  keep  the  blood-pressure 
constantly  low  it  is  very  convenient,  an  eighth 
to  half  a  grain  or  even  more  being  taken  every 
two,  four,  or  six  hours,  more  or  less,  as  the  case 
requires.  Nitromannitol  may  also  be  used  in 
doses  of  one  grain  or  more.  Where  the  pulse 
is  very  quick,  aconite  or  colchicum  may  be 
given  and  general  bleeding  may  be  required. 

Classes  of  Vaso  -  dilators. — The  chief  vaso  - 
dilators  are  amyl  nitrite  and  other  nitrites 
belonging  to  the  aliphatic  series  and  nitrites  of 
the  alkali  metals,  the  chief  of  those  being  nitrite 
of  soda.  Some  nitrates,  such  as  nitroglycerine, 
nitroerythrite,  nitromannitol,  although  they 
are  nitrates,  have  a  rapid  effect  on  the  blood- 
pressure,  and  so  has  hydroxylamine.  Nitrates 
such  as  nitrate  of  potash  seems  to  have  an 
action  of  the  same  sort,  though  not  so  rapid 
or  powerful,  but  is  longer  continued.  In  full 
doses  they  all  act  directly  upon  the  capillaries, 
causing  them  to  dilate  ;  but  in  the  case  of  nitrite 
of  amyl,  and  probably  the  other  aliphatic  nitrites, 
the  dilating  centre  in  the  medulla  appears  to  be 
affected  first,  so  that  the  dilatation  is  of  two-fold 
origin,  central  and  peripheral.  Another  group  of 
vaso-dilators  contains  benzoates  and  hippurates. 


340    ACTION  OF  DRUGS  ON  BLOOD-VESSELS 

The  kidney  possesses  a  remarkable  reciprocat- 
ing action  in  regard  to  the  benzoates,  for 
Schmiedeberg  has  found  that  if  benzoic  acid  is 
added  to  the  blood  perfused  through  the  kidney, 
hippuric  compound  appears  in  the  urine,  while  if 
hippuric  acid  is  added  to  the  blood,  benzoic  acid 
appears  in  the  urine.18  Guipsine  is  obtained  from 
mistletoe,  and  is  said  to  have  a  dilating  effect 
upon  the  vessels,  so  that  it  reduces  blood- 
pressure.19 

Iodides. — Iodides  differ  from  vaso  -  dilators 
already  mentioned  in  so  far  that  when  injected 
into  a  vein  they  have  no  immediate  effect  on 
the  blood-pressure,20  but  when  administered  for 
a  length  of  time  they  certainly  appear  to  lower 
it.  The  most  commonly  used  is  the  iodide  of 
potassium,  but  if  the  heart  be  feeble  and  the 
depressing  effect  upon  the  heart  at  all  feared, 
the  iodide  of  sodium  may  be  used  in  its  place. 
One  drawback  to  the  use  of  either  iodide  of 
potassium  or  sodium  is  its  exceedingly  disagree- 
able taste,  which  remains  almost  constantly  in 
the  mouth.  The  reason  of  this  is  that  the 
iodides  are  secreted  with  extreme  rapidity  by 
the  salivary  glands.  The  saliva  is  swallowed, 
absorbed  by  the  stomach,  and  again  excreted  by 
the  saliva,  so  that  its  taste  remains  in  the  mouth 
a  long  time.  Iodides  have  also  the  power  of 
causing  other  substances  which  are  not  usually 
secreted  by  the  salivary  glands  to  pass  into  the 
saliva.  Thus  Claude  Bernard 21  found  that  when 
lactate  of  iron  was  injected  into  the  artery  of 
the  submaxillary  gland,  it  did  not  appear  in  the 
saliva,  but  did  so  if  it  was  mixed  with  a  solution 


IODIDES  34! 

of  iodide  of  potassium  previous  to  injection.  I 
think  that  iodides  exercise  a  similar  effect  upon 
quinine,  because  the  out-patients  at  St  Bartholo- 
mew's Hospital  almost  unanimously  refused  to 
take  a  draught  containing  quinine  with  iodide 
of  potassium,  on  account  of  the  bitter  taste  being 
present  in  the  mouth  the  whole  day.  Some 
patients  complain  of  a  similar  bitter  taste  during 
the  use  of  iodides  although  these  are  not  accom- 
panied by  any  bitter  medicines.  In  such  cases 
I  am  inclined  to  think  that  the  bitter  taste  is 
due  to  some  autotoxin — perhaps  peptotoxin — 
or  other  bitter  substance  in  the  bile,  and  a 
mercurial  purgative  followed  by  a  saline  may 
remove  it.  The  taste  may  be  covered  to  a 
considerable  extent  by  means  of  saccharin, 
the  quantity  ^required  being  in  proportion  to  the 
dose  of  iodfde.  Chloroform  water  also  covers 
the  taste,  and  so  does  liquorice.  Some  patients 
dislike  the  taste  and  look  of  liquorice,  so  that 
iodide  of  potassium  given  with  chloroform  water 
and  a  little  tincture  of  lemon  or  orange  to 
cover  the  taste  makes  an  elegant  prescription. 
After  a  good  many  trials  I  find  the  following 
prescription  to  be  the  best : — 

$     Potassii  iodidi  .  gr.  v. 

Tinct.  Limonis  .  3ss. 

Elixir  glusidi  .  tiiv. 

Aquam          .  .  ad  3j- 

Ft.  Mist.         M. 

Each  fluid  drachm  contains  5  grs.  of  potassium 
iodide  According  to  the  dose  desired,  I,  2,  3,  or 
4  fluid  drachms  are  to  be  taken  in  half  a  tumblerful 
or  more  of  soda  water.  It  is  most  convenient  to  have 
the  soda  water  in  a  syphon,  and  having  put  the  requisite 


342    ACTION  OF  DRUGS  ON  BLOOD-VESSELS 

quantity  of  the  iodide  solution  in  a  tumbler,  to  add  the 
soda  water  and  drink  during  effervescence.  Some 
patients  find  that  5  minims  of  elixir  glusidi  make  the 
mixture  too  sweet,  and  for  them  the  quantity  may  be 
lessened  whilst  a  larger  quantity  of  lemon,  such  as  i 
fluid  drachm  of  the  tincture,  is  more  pleasing  to  the 
palate.  Iodide  of  sodium  may  be  used  in  place  of  iodide 
of  potassium  when  desired.  As  the  medicine  has 
frequently  to  be  taken  by  patients  suffering  from  arterio- 
sclerosis three  or  four  times  a  day  for  many  weeks  at  a 
time,  it  is  of  considerable  importance  that  the  form  in 
which  it  is  administered  shall  be  as  little  disagreeable  as 
possible. 

Iodide  is  generally  given  in  doses  of  5  to  10  grs. 
three  times  a  day,  but  in  some  cases  it  answers 
as  well,  or  better,  to  give  a  dose  of  30  grs.  at 
bedtime.  In  some  people  it  brings  on  running 
at  the  nose  and  salivation,  and  in  one  case  I 
have  seen  it  produce  abdominal  pain  and 
tenderness  all  over  the  pancreas  and  limited 
to  it,  as  if  its  action  on  the  pancreas  had  been 
the  same  as  on  the  salivary  glands.  The  curious 
point  is  that  while  2  or  3  grs.  cause  the  nose  to 
run  very  freely,  20  grs.  rarely  do  so,  so  that 
the  coryza  may  be  stopped  either  by  giving  up 
the  medicine  or  by  doubling  the  dose.  With 
very  large  doses  pustular  eruptions  arc  likely  to 
occur,  and  to  prevent  these  small  doses  of 
arsenic  are  frequently  given  along  with  the 
iodide.  Locally  the  pustules  may  be  treated 
with  an  antiseptic  ointment,  such  as  carbolic 
acid  ointment,  and  ointment  of  ammoniated 
mercury  may  also  be  employed,  but  should  only 
be  tried  on  a  few  at  a  time,  as  it  may  possibly 
give  rise  to  increased  irritation. 

The    Effect   of  Drugs   upon    the    Coronary 


DRUGS  ON  CORONARY  ARTERIES      343 

Arteries. — If  the  coronary  arteries  were  affected 
by  drugs  in  the  same  way  as  the  other  vessels, 
the  consequence  would  be  that  just  at  the 
time  when  the  blood  -  pressure  was  raised 
throughout  the  body  the  supply  of  blood  to 
the  heart  would  be  diminished,  and  the  power 
of  the  heart  consequently  lessened  at  the  very 
time  it  was  called  upon  to  do  more  work.  But 
the  contrary  is  the  case,  and  many  drugs  which 
contract  the  vessels  of  the  rest  of  the  body  cause 
dilatation  of  the  coronary  arteries.  The  way  in 
which  the  action  of  drugs  upon  these  vessels  is 
usually  investigated  is  to  put  a  cannula  into  one 
of  the  branches  of  the  coronary  artery  and  note 
the  rate  at  which  blood  flows  out  before  and 
after  the  administration  of  the  drug.  The 
experiments  are  made  either  upon  the  heart  in 
situ  or  removed  from  the  body  and  perfused 
with  a  nutrient  fluid.  When  the  experiments 
are  made  upon  the  heart  in  situ,  the  result  is  a 
mixed  one,  for  it  depends  not  only  upon  the 
size  of  the  coronary  vessels,  but  upon  the  general 
blood-pressure  which  drives  the  blood  through 
this.  Thus  a  drug  which  raises  the  general 
blood-pressure,  such  as  digitalis,  may  increase 
the  rapidity  of  flow  through  the  coronary  arteries 
without  really  dilating  them,  because  while  their 
size  remains  the  same,  the  greater  pressure  of 
blood  in  the  aorta  will  naturally  drive  more 
blood  through  them  in  a  given  time.  In  the 
same  way  a  drug,  such  as  nitrite  of  amyl,  may 
lessen  the  amount  of  blood  passing  through  the 
coronary  arteries  even  though  it  actually  dilates 
them,  because  it  lowers  the  blood-pressure  in 


344    ACTION  OF  DRUGS  ON  BLOOD-VESSELS 

the  aorta.  In  experiments  upon  an  excised 
heart  this  factor  can  be  eliminated,  because  the 
pressure  under  which  the  perfused  fluid  is 
forced  through  the  heart  may  be  kept  alike. 
The  coronary  artery  is  dilated  by  adrenalin,  by 
the  digitalis  group  of  substances,  by  caffeine, 
and  by  theobromine.22  It  has  been  said  by  G.  S. 
Bond  that  the  out-flow  from  the  coronary  veins 
is  lessened  by  nitro-glycerine  and  amyl  nitrite.23 
As  I  have  already  explained,  however,  this 
lessening  may  be  due  to  a  simple  fall  of  the 
general  blood-pressure ;  and  in  one  experiment 
made  by  Professor  Kronecker  and  myself,  we 
found  that  the  out-flow  was  increased  enor- 
mously by  amyl  nitrite,  notwithstanding  the 
general  fall  of  blood-pressure.  Such  a  dilating 
action  of  amyl  nitrite  and  nitro-glycerine  upon 
the  coronary  vessels  would  readily  explain  the 
relief  they  offer  in  angina  pectoris,  even  in  cases 
where  the  blood-pressure  is  normal. 


LITERATURE. 

1  D.  Cow,  Joiirn.  of  Physiol.,  1911,  vol.  xlii.,  p.  132. 

2  Ludwig  and  Mosso,  vide  Lauder  Brunton,  Text  Book 

of  Pharmacology,  Therapeutics,  and  Matcria  Medico, 
1885  (Macmillan  &  Co.),  p.  241. 

3  Gaskell,  Journ.  of  Physiol.,  1880-2,  vol.  iii.,  p.  53. 

4  Boehm,  Arch.  f.  exper.  Path.   //.  Pharm.,   1875,  Bd. 

iii.,    p.    216;    Ringer    and    Sainsbury,   Brit.   Med. 
Joiirn.,  1883,  vol.  ii.,  p.  265  ;  D.  Cow,  loc.  cil ,  p.  134. 
6  D.  Cow,  loc.  cit.,  p.  132. 

6  D.  Cow,  loc.  cit.,  p.  134. 

7  Gottlieb  and  Magnus,  Arch.  f.  exper.  Path.  u.Phatm., 


LITERATURE  OP  CHAPTER  XIV.       345 

1901,  Bd.  xlvii.,  p.  135  ;  Loewi  and  Jonescu,  ibid., 
1908,  Bd.  lix.,  p.  71. 

8  Wertheimer  und  Delezenne,  Compt.  rend.  d.  I.  Soc.  de 

BioL,  1897,  p.  633. 

9  Meyer  and  Gottlieb,  Exper.  Pharmakologie,  1910,  pp. 

232-3. 
0  F.  Guthrie,  Journ.  of  Chem.  Soc.,  1859,  vol.  xi.,  p.  245. 

11  Lauder  Brunton,  Lancet,  27th  July  1867,  p.  97  ;   re- 

printed in  Collected  Papers,  First  Series,  p.  137 
et  seq. 

12  Brunton  and  Tait,  St  Bartholomew 's  Hospital  Reports, 

1876,  vol.  xii.,  p.  144;  reprinted  in  Collected  Papers, 
First  Series,  p.  474  et  seq: 

13  W.  Murrell,  Lancet,  1879,  v°l-  i->  PP-  80,  113,  151,  225. 

14  M.  Hay,  Practitioner,  vol.  xxx.,  pp.  179-194,  321-330  ; 

Brit.  Med.  Journ.,  1883,  vol.  ii.,  p.  1095. 
16.Cash  and  Dunstan,  Phil.  Trans.,  1893,  vol.  clxxxiv., 
pp.  505-639. 

16  Brunton   and  Bokenham,  Roy.  Soc.  Proc.,  1889,  vol. 

xlv.,  p.  352. 

17  D.  J.  Leech,  Pharmacological  Action  and  Therapeutical 

Uses  of  the  Nitrites  and  Allied  Compounds.  Edited 
by  R.  B.  Wild  (Manchester:  Sherratt  &  Hughes, 
1902). 

18  Bunge  and  Schmiedeberg,  Arch.  f.  exper.  Path.  u. 

Pharm.,  1877,  Bd.  vi.,  p.  233  ;  Schmiedeberg,  ibid., 
1881,  Bd.  xiv.,  pp.  288,  379. 

18  Gaultier  and  Chavalier,  Compt.  rend.,  25th  Nov. 
1907,  vol.  cxlv.,  p.  941  ;  O.  K.  Williamson,  Practi- 
tioner, 1911,  p.  690. 

20  Stockmann  and  Charteris,  Brit   Med.  Journ.,  1901, 

vol.  ii.,  p.  1520. 

21  Claude   Bernard,  Lemons    de  Physiol.   experimental, 

1856  (Paris  :  J.  B.  Bailliere),  Tome  ii.,  p.  99. 

22  D.  Cow,  loc.  cit.,  p.  132  et  seq. 

23  G.  S.  Bond,  Journ.  of  exper.  >  Medicine,  1910,  vol.  xii., 

pp.  580-1. 


2  A 


CHAPTER   XV 

ACTION   OF  DRUGS   ON    URINARY,  DIGESTIVE, 
AND   NERVOUS  SYSTEMS 

Drugs  acting  on  the  Kidneys,  Digestive  Organs,  and  Ner- 
vous System — Diuretics — Mercury  as  a  Diuretic — 
Uses  of  Tapping — Purgatives — Mercurials — Gastric 
Disinfectants  —  Swallowing  Air  —  Alkalies  —  Sour 
Milk  —  Intestinal  Disinfectants  —  Carminatives  — 
Adjuvants  to  Carminatives — Narcotics. 

Diuretics. — The  secretion  of  urine  depends 
to  a  great  extent  on  the  pressure  of  blood 
in  the  glomeruli  of  the  kidney,  and  Ludwig1 
showed  that,  as  a  general  rule,  the  higher  the 
pressure  within  the  glomeruli,  the  more  rapid 
is  the  secretion  of  urine.  This  is  generally 
known  as  Ludwig's  theory  of  the  secretion  of 
urine.  For  a  number  of  years  he  looked  upon 
the  transudation  of  fluid  through  the  glomeruli 
under  pressure  as  the  main  factor  in  secretion, 
and  thought  that  the  fluid  thus  exuded  under- 
went concentration  by  absorption  of  its  watery 
constituents  in  its  passage  through  the  tubules. 
In  1870,  however,  he  modified  his  theory  con- 
siderably in  the  direction  of  Bowman's  original 
one,2  so  that  latterly  Bowman  and  Ludwig's 
theories  very  nearly  coincided.  Bowman  held 

846 


DIURETICS  347 

that  the  watery  part  of  the  urine  transuded 
from  the  glomeruli,  while  the  solid  constituents 
were  excreted  by  epithelium  of  the  tubules. 
Bowman  came  to  this  conclusion  on  anatomical 
grounds  alone,  while  Ludwig  founded  his  theory 
on  actual  experiment.  The  proportion  of  salts 
and  of  water  which  the  kidney  must  excrete 
in  order  to  maintain  the  proper  proportion 
of  these  in  the  body  varies  enormously  under 
different  conditions.  Thus  people  living  on  a 
more  or  less  liquid  diet,  with  a  small  propor- 
tion of  proteins,  such  as  a  diet  consisting  of 
bread,  butter,  tea,  and  farinaceous  foods 
generally,  with  a  little  milk,  must  excrete  a 
large  quantity  of  water  and  only  a  very  small 
proportion  of  urea,  or  other  products  of  nitro- 
genous waste.  On  the  other  hand,  especially 
if  the  skin  is  acting  but  slightly,  people  living 
in  hot  climates,  such  as  South  Africa  or  South 
America,  living  upon  a  highly  nitrogenous 
diet,  such  as  dried  meat,  and  with  a  small 
proportion  of  water,  must  retain  water  as  much 
as  possible  in  their  bodies,  and  at  the  same 
time  excrete  a  large  quantity  of  urea.  In  the 
kidney  we  find  a  provision  by  which  this  can 
be  effected.  Not  only  can  the  vessels  of  the 
kidney  be  dilated  by  the  action  of  drugs  while 
other  vessels  throughout  the  body  are  con- 
tracted, but  the  kidney  contains  some  mechanism 
by  which  the  blood  going  to  it  through  the 
renal  artery  may  be  sent  at  one  time  almost 
exclusively  through  the  glomeruli,  so  that 
much  water  can  be  excreted  and  little  solid ; 
and  at  another  time  almost  exclusively  to  the 


348 


tubules,  so  that  much  solid  can  be  excreted 
and  but  little  water.  This  can  be  more  easily 
understood  by  the  help  of  a  diagram  of  Hans 
Meyer's.3 


Rena-l, 


recta, 


Fio.  101 — Diagram  to  show  the  by-pass  whereby  blood  may  go  to  the 
plexus  surrounding  the  tubules  and  supply  material  for  excretion  of 
solids  without  passing  through  the  glomerulus  and  losing  water. 
(After  Meyer  and  Gottlieb.) 

We  may  divide  diuretics  into  five  groups : — 
I.  What  we    may  call  the    natural  diuretics, 


Branch  of  renal  artery. 
Afferent  artery  to  the  glomerulus. 


Connecting  branch. 
By -pass   artery  going  directly  to 
the  plexus  (corresponding  to 
of  the  arterise  reel »•). 

Glomerulus  with  efferent  artery. 


'to\ 

ne  > 


Union     of     arterial    and    venous \ 
branches  to  form  the  plexus.       / 

Portal  vein  of  the  kidney. 
Urinary  tubule. 


Fio.  102.—  Diagram  of  the  circulation  in  the  kidney  of  the  newt.  Modified 
from  Nussbaum,  and  arranged  to  show  the  parts  of  the  kidney  which 
are  probably  affected  by  different  diuretics.  (From  Lander  Brunton's 
Pharmacology  and  Therapeutics,  p.  878, 1st  Ed.  London  :  Macmillan, 
1885.) 

water,    urea,    and    purin    bodies    allied    to    it 
(p-    317)>  caffeine,    theobromine,  theophylline, 


GROUPS  OF  DIURETICS  349 

and  theocin.  These  bodies  increase  the 
rapidity  of  the  circulation  through  the 
kidney,  and  increase  the  amount  of  water 
poured  out  through  the  glomeruli,  but  at  the 
same  time  they  probably  interfere  with  the 
reabsorption  in  the  tubuli,  as  indigo  carmine 
injected  along  with  caffeine  does  not  appear 
in  the  epithelium  of  the  tubules  as  it  would 
do  if  injected  alone.  In  all  probability,  how- 
ever, caffeine  not  only  tends  to  prevent 
reabsorption,  but  to  stimulate  secretion  by 
the  cells  of  the  tubules. 

2.  The  second   and    third   groups   alter   the 
circulation  in  the  kidney.   The  second  group  con- 
tains the  substances  which,  like  digitalis,  dilate 
the  vessels  of  the  kidney  but  also  at  the  same 
time  contract  those  of  the  body  generally.    The 
blood   is  thus  driven  under  a  higher  pressure 
than  normal  through  the  dilated  afferent  arteries 
of  the  kidney,  so  that  the  circulation  through 
the  organ  becomes  much  more  rapid,  and  the 
secretion  of  urine  very  greatly  increased.     The 
dilating  effect  upon  the  renal  arteries  may  be 
sufficient    to    produce    diuresis,    although   the 
contraction  of  arteries  in  the  rest  of  the  body 
may  not  be  sufficient  to  raise  the  blood-pressure. 
When  the  drugs  are  given  in  too  large  doses, 
they  may  cause  such  great  contraction  of  the 
renal  vessels  as  to  arrest  the  circulation  and  stop 
the  secretion  of  urine. 

3.  The  third  group  contains  those  drugs  which 
dilate  the  vessels  of  the  body  generally,  includ- 
ing those   of   the   kidneys.      Such   substances 
may    dilate    the    vessels    of    the     kidney    so 


350  ACTION  OF  DRUGS 

much  as  to  produce  diuresis  in  spite  of  lowering 
the  blood-pressure  generally.  Thus  nitrite  of 
ethyl  in  the  form  of  nitrous  ether  has  long  been 
recognised  as  a  most  useful  diuretic,  and  nitrite 
of  soda  increases  the  secretion  of  urine  even 
when  the  blood-pressure  is  below  normal. 

4.  The  fourth  group  contains  the  ethereal  oils, 
such  as  oil  of  juniper.     I  do  not  know  that  the 
mode  of  action   of  these    has    been   precisely 
ascertained,  but  in  all  probability  they  act  upon 
the  tubules. 

5.  The   fifth   division  of  diuretics   is  that  of 
salines,  such  as  potassium  tartrate,  and  acetate, 
and  also  sodium  sulphate.     According  to  Meyer 
and  Gottlieb,  these  salines  have  an  action  on 
the  kidney  similar  to  what  they  have  on  the 
intestine,  causing   secretion   in   one    part   and 
preventing    absorption    in    another.       In     the 
kidney  they  probably  increase  the   exudation 
of  fluid  through  the  glomerulus  and  prevent  its 
reabsorption  in  the  tubule,  or,  as  Meyer  puts 
it,  they  cause  diarrhoea  of  the  tubules.4 

Mercury  as  a  Diuretic. — The  effect  of  small 
doses  of  mercury  and  calomel  in  producing  or 
increasing  diuresis  has  long  been  known,  and 
one  of  the  best  diuretics  in  cardiac  disease  is 
certainly  the  old-fashioned  pill,  which  is  I  gr. 
each  of  powdered  digitalis,  squill,  and  blue  pill. 
The  action  of  calomel  is  said  by  Fleckseder 5  to 
be  due  to  the  profuse  secretion  of  saliva  and 
intestinal  juice,  which  lessens  the  proportion  of 
water  in  the  blood,  and  thus  leads  to  absorption 
from  cedematous  tissue.  If  the  watery  contents 
of  the  intestine  are  evacuated  there  is  no 


MERCURY  AS  DIURETIC  351 

diuresis,  but  if  they  are  retained,  the  kidneys 
excrete  the  extra  amount  of  water,  and  thus 
calomel  diarrhoea  and  calomel  diuresis  are 
vicarious.  This  hypothesis  is  not  quite  satis- 
factory because  the  beneficial  effect  of  mercury 
in  aiding  diuresis  frequently,  indeed  generally, 
occurs  without  any  apparent  increase  of  the 
salivary  secretion.  Locke's  idea  is  that  mercury 
acts  indirectly  on  the  urine  by  increasing  the 
formation  of  urea  in  the  liver,  and  the  larger 
amount  of  urea  acting  as  a  diuretic.6 

It  is  just  possible  that  the  effect  of  mer- 
cury may  be  due  to  some  alteration  which 
it  produces  in  the  vicosity  of  the  blood  and 
consequent  freedom  of  flow  through  the  glomer- 
uli  of  the  kidneys.  The  exact  action  of  mercury 
on  the  blood  is  not  at  present  known,  but  it  is 
evident  that  when  pushed  to  the  extent  of 
salivation  it  was  found  to  have  a  profound 
effect  upon  the  blood,  as  shown  by  the  alteration 
it  produced  in  its  characters  at  the  time  when 
blood-letting  was  frequently  used  along  with 
salivation. 

Uses  of  Tapping. — The  secretion  of  the  kid- 
ney depends  very  greatly  upon  the  rapidity  of 
the  circulation  through  it,  and  if  either  the  veins 
or  the  tubules  are  obstructed,  pressure  is  exerted 
on  the  glomeruli,  and  the  circulation  is  greatly 
diminished  with  consequent  lessening  in  the 
amount  of  urine  secreted.  The  backward 
pressure  of  the  blood  in  mitral  disease  tends 
to  increase  the  pressure  in  the  veins,  as  shown 
in  B,  Fig.  103,  and  this  not  only  compresses  the 
arterioles  but  leads  to  albumin uria.  A  similar 


352 


ACTION  OF  DRUGS 


effect  is  produced  by  obstruction  to  the  flow 
of  urine  through  the  ureter,  and  consequently 
through  the  tubules,  as  shown  in  C,  Fig.  103. 
When  the  abdomen  is  distended  with  ascites, 
pressure  is  exerted  both  on  the  renal  veins  and 


FIG.  103 Diagram  to  show  the  effect  of   venous  congestion  and  o 

obstruction  of  the  ureter  or  tubules  on  the  kidney.  A,  normal  kidney, 
with  artery  in  the  centre  of  the  hilus.  The  artery  ends  in  a  glomerulus 
from  which  a  urinary  tubule  passes  into  the  ureter,  which  is  shown 
passing  out  of  the  hilus  below  the  artery.  The  renal  vein  is  shown 
above  the  artery  in  the  hilus.  B  shows  congestion  of  the  vein,  with 
consequent  compression  of  the  artery  and  tubule.  C  shows  obstruc 
tion  of  the  ureter  and  tubules. 


Pio.  104. — Diagrammatic  section  of  the  abdomen :  A,  in  the  normal 
state ;  B,  in  advanced  dropsy,  where  the  ascitic  fluid  compresses  the 
kidney  itself  and  also  the  ureter,  so  that  the  secretion  of  urine  is 
hindered  in  two  ways :  (1)  by  pressure  on  the  outside  of  the  kidney, 
and  (2)  by  pressure  on  the  inside  of  the  kidney  from  the  tension  in  the 
urinary  tubules. 


on  the  ureter  (Fig.  104),  and  thus  diuretics  may 
fail  to  act  unless  the  pressure  is  removed  by 
tapping. 

Purgatives.  —  Free     purgation     not     only 
removes   the    intestinal    contents  quickly   and 


TAPPING—PURGA  T1VES— MERCURIALS      353 

prevents  to  a  considerable  extent  the  formation 
of  toxamines,  but  some  purgatives  cause  great 
secretion  of  watery  fluid  in  the  intestine,  and 
thus  lessen  the  proportion  of  water  in  the  blood* 
In  consequence  of  this,  absorption  takes  place 
from  the  cedematous  tissues.  The  best  of  such 
hydrocathartics  which  has  retained  its  place  in 
practice  for  many  years  is  the  compound  jalap 
powder.  The  bitartrate  of  potash  which  it  con- 
tains tends  to  produce  a  flow  of  watery  fluid 
into  the  intestine,  while  the  jalap  by  stimulating 
intestinal  peristalsis  causes  the  water  to  be 
evacuated  and  prevents  reabsorption.  The 
action  of  the  jalap  powder  may  be  increased  by 
giving  a  teaspoonful  of  potassium  bitartrate 
along  with  the  usual  30  grs.  of  the  compound 
jalap  powder.  Elaterium  or  compound  powder 
of  elaterin  is  a  very  powerful  hydrocathartic, 
but  on  account  of  the  depression  it  produces 
must  be  used  with  more  care,  and  is  not  so  well 
adapted  for  general  use  as  the  compound  jalap 
powder.  There  is  a  considerable  difference 
between  the  action  of  such  purgatives  as  those 
just  named  and  mercurials.  These  act  generally 
upon  the  lower  parts  of  the  small  and  the  whole 
of  the  large  intestine.  They  have  not  the  same 
action  as  mercurials  upon  the  removal  of  bile. 

Mercurials. — They  do  not  really  increase  the 
secretion  of  bile;  on  the  contrary,  they  may 
lessen  it,  but  they  do  appear  to  have  the  power 
of  removing  bile  from  the  body.  It  has  been 
shown  that  the  green  motions  which  so  often 
occur  after  calomel  owe  their  colour  to  bile. 
By  removing  bile  from  the  body  one  is  able  to 


354 


ACTION  OF  DRUGS 


remove  also  the  toxins  which  may  be  contained 
in  the  bile.  Various  toxins  formed  in  the 
intestine  as  well  as  poisons  which  have  been 
ingested  are  absorbed  from  the  intestine  and 
carried  by  the  portal  vein  to  the  liver  and  are 
excreted  in  the  bile,  in  which  they  pass  again 


Liver 


.^Stomach 


Large 

..  .intestine 


FIG.  105. — Diagram  to  illustrate  the  entero-bepatic  circulation  and  reten- 
tion of  bile  and  toxins  in  the  body. 

to  the  intestine.  There  they  undergo  absorp- 
tion a  second  time,  and  in  this  way  poisons  may 
circulate  for  a  long  time  from  the  intestine  to 
the  liver  and  back  again  without  leaving  the 
body,  although  small  quantities  may  be  con- 
stantly passing  into  the  blood.  Probably  it  is 
by  the  removal  of  toxins  that  mercury  in  its 
various  preparations  proves  such  a  useful 
adjunct  to  other  drugs  in  the  treatment  ot 


GASTRIC  DISINFECTANTS  355 

disorders  of  the  circulation.  Its  action  should 
be  supplemented  by  some  saline  to  sweep  the 
toxins  out  of  the  intestines,  as  if  they  remain 
in  the  upper  part  they  may  again  undergo 
reabsorption. 

Gastric  Disinfectants. — Most  toxins  belong 
to  the  aromatic  series  and  are  derived  from 
albuminoid  bodies.  The  chief  gases  in  the 
intestine  are  carbonic  acid  and  marsh  gas,  and 
these  are  formed  chiefly  by  the  fermentation 
of  carbohydrates.  Normal  gastric  juice  has  an 
antiseptic  action,  and  when  the  food  is  well 
digested  in  the  stomach  there  is  less  chance  of 
either  toxins  or  gases  being  formed  from  it 
in  the  intestine.  If  the  gastric  juice,  however, 
is  much  diluted  by  fluid  taken  during  the  meal 
it  will  not  exert  this  action,  and  in  addition  the 
albuminous  food  will  be  less  broken  up  in  the 
stomach  and  pass  into  the  intestine  in  larger 
masses.  One  great  rule  to  prevent  flatulence, 
therefore,  is  to  give  solids  and  liquids  separately, 
and  if  this  is  not  sufficient  to  prevent  fermenta- 
tion it  may  be  advisable  to  give  carbohydrates 
such  as  bread  and  starchy  food  at  one  meal, 
and  proteins  such  as  eggs,  milk  and  cheese  at 
another.  In  all  cases  it  is  advisable  to  have 
the  food  thoroughly  masticated  before  it  is 
swallowed.  It  is  to  be  remembered  that  when 
gastric  digestion  is  active  the  production  of  gas 
either  in  the  stomach  or  intestine  is  likely  to 
be  diminished,  and  the  administration  of  pepsin 
or  other  digestive  ferments  tends  both  to 
help  the  digestion  of  the  food  and  lessen  the 
production  of  gas. 


356  ACTION  OF  DRUGS 

Swallowing  Air. — This  is  another  cause  of 
flatulence.  It  occurs  frequently  from  irritation 
of  the  stomach  by  acidity,  so  that  more  saliva 
flows  into  the  mouth,  and  this  occasions  a  con- 
stant tendency  to  swallow.  Flatulence  arising 
from  this  cause  is  often  prevented  by  the  use 
of  bismuth  and  bicarbonate  of  soda  to  lessen  the 
irritation  in  the  stomach.  The  most  common 
gastric  antiseptics  are  sulpho-carbolate  of  soda 
in  doses  of  5  to  1 5  grs.,  carbolic  acid  in  doses  of 
i  to  3  grs.  in  the  form  of  pill  or  capsule,  creasote 
i  to  5  minims  usually  given  in  capsule,  naphthol 
in  doses  of  3  to  10  grs.  in  a  cachet.  Beta- 
naphthol  is  more  commonly  employed  than 
alpha-naphthol,  for  though  the  latter  is  a  stronger 
and  more  powerful  antiseptic,  it  is  more  irritating 
to  the  stomach.  Vegetable  charcoal  is  a  useful 
remedy,  and  may  be  given  in  the  form  of 
biscuits  or  powder.  The  powder  may  be  simply 
mixed  with  water  or  swallowed  in  a  cachet  or, 
what  is  easier,  given  as  a  wafer.  Peroxide  of 
magnesia  is  both  antiseptic  and  antacid.  It  is 
usually  given  in  doses  of  one-third  of  a  tea- 
spoonful  with  water  or  it  may  be  combined 
with  charcoal.  Some  biscuits  are  in  the  market 
containing  these  two  substances. 

Alkalies. — When  much  acid  is  present  in  the 
stomach,  it  may  cause  a  good  deal  of  reflex 
irritation,  and  possibly  may  even  lead  to  cardiac 
disturbance  and  faintness  (p.  179).  It  is  most 
readily  neutralised  by  means  of  bicarbonate  of 
soda,  of  which  half  a  teaspoonful  or  even  more 
may  be  put  into  a  tumbler  of  water,  and  slowly 
sipped  till  the  desired  result  is  obtained.  The 


ALKALIES  357 

disagreeable  taste  of  this  is  to  a  great  extent 
removed,  if  a  small  crystal  of  citric  acid  is 
dropped  into  the  tumbler.  This  causes  the 
disengagement  of  carbonic  acid,  and  this  effer- 
vescent mixture  is  much  pleasanter  than  the 
simple  solution.  The  carbonic  acid  also  tends 
to  make  the  bicarbonate  dissolve  more  readily, 
and  quite  a  small  crystal  of  •  citric  acid  is 
sufficient,  so  small  as  by  no  means  to  neutralise 
a  quarter  of  the  bicarbonate.  This  mixture 
frequently  acts  as  a  powerful  carminative,  and  if 
desired  may  be  given  along  with  other  carmina- 
tives. Half  a  teaspoonful  or  a  teaspoonful  of 
sal  volatile  in  2  or  3  ozs.  of  water  may  also  be 
used  in  place  of  the  bicarbonate  of  soda,  and  has 
a  more  stimulating  action  on  the  heart  if  this 
should  be  feeble.  Magnesium  hydroxide  also 
acts  as  a  powerful  antacid,  and  may  be  given 
in  almost  any  quantity,  though  usually  half  a 
teaspoonful  to  two  teaspoonfuls  is  sufficient. 
In  the  form  of  magnesia  cream  it  is  more 
palatable  than  in  the  form  of  the  dried  powder. 
The  effect  of  alkalies,  which  at  the  same  time 
act  as  carminatives,  upon  irregular  action  of  the 
heart  or  tachycardia  is  sometimes  extraordinary, 
the  intermittence  disappearing,  or  the  pulse 
returning  to  its  normal  rate  almost  immediately 
after  the  expulsion  of  a  large  volume  of  flatus 
from  the  stomach,  and  the  consequent  removal 
of  reflex  irritation  of  the  heart  through  the 
gastric  branches  of  the  vagus  (Fig.  106). 

Sour  Milk. — The  gases  which  produce  flatu- 
lence in  the  intestine  are  chiefly  marsh  gas  and 
carbonic  acid.  The  substances  from  which  they 


358  ACTION  OF  DRUGS 

are  most  readily  produced  are  the  carbohydrates, 
such  as  starch,  sugar,  and  cellulose.  Milk  sugar 
is  not  so  readily  fermented  as  other  sugars,  and 
milk  in  its  ordinary  state  when  taken  without 
any  carbohydrates  does  not,  as  a  rule,  produce 
flatulence,  and  a  few  days  of  pure  milk  diet  may 
greatly  lessen  the  production  of  gas.  According 


MEDULLA 

\     I     OBLONC.ATA 


HEART  ///)i     \"  \-*FF&&rr 

HEART     ,     ;    /     /         \         ,     NERVE,; 

(    "IX''  'i 

„-,,       .    I  ..  J-- STOMACH 

r/f  -       VW-IHHIBIT, 

I  v  '^—^.2!     I   WEWI/E;; 

ty-\-      IHTE.,TINAL 
INTE r,7INE-  .    -'  i/r--<;r/o 


FIG.  106.— Diagram  to  show  the  nervous  mechanism  by  which  the  action 
of  the  heart  may  be  depressed  by  irritation  of  the  stomach.  The 
reflex  irritation  of  the  vagus  may  render  the  heart's  action  simply 
weak,  or  slow  and  weak. 

to  Metchnikoflf7  the  lactic  acid  bacillus  tends  to 
destroy  other  bacilli  of  a  pathogenic  nature  in 
the  intestine,  and  thus  to  prevent  the  formation 
of  toxic  products.  Milk  which  has  been  rendered 
sour  by  the  addition  of  the  lactic  acid  bacillus 
thus  tends  to  sterilise,  in  a  measure,  the  whole 
intestinal  tract  by  destroying  all  other  bacilli 
excepting  itself.  It  is  best  to  render  the  milk 


LACTIC  ACID  THERAPY  359 

acid  by  the  addition  of  the  bacillus  acidi  lactici 
before  giving  it,  but  sometimes  when  this  can 
not  be  done  the  lactic  acid  bacillus  may  be  given 
in  tablets  ;  but  this  method  of  giving  it  is  not  so 
satisfactory.  It  is  very  important  that  a  pure 
strain  of  the  bacillus  should  be  obtained,  because 
if  the  bacillus  butyricus  is  mixed  with  it,  it 
renders  the  milk  not  only  offensive  to  the  taste 
and  smell,  but  very  irritating  to  the  stomach  and 
intestines.  Milk  may  be  readily  soured  each 
time  by  the  addition  of  bacilli  in  tablets  to  the 
fresh  milk ;  but  instead  of  this  it  is  better  when 
once  a  good  strain  of  sour  milk  has  been  obtained, 
to  add  a  little  of  it  to  the  fresh  milk  instead  of 
adding  new  tablets.8 

Intestinal  Disinfectants. — The  same  disin- 
fectants which  are  useful  for  the  stomach  are 
also  useful  in  the  intestine.  One  of  the  most 
powerful  perhaps  is  mercury  in  various  forms.  A 
solution  of  the  perchloride  is  sometimes  useful,  in 
doses  of  half  a  drachm  to  a  drachm  repeated 
every  four  to  six  hours.  It  has  a  very  disagree- 
able taste,  so  it  is  preferable  to  give  it  in  the 
form  of  pill  in  the  dose  of  one  thirty  -  second 
to  one  -  sixteenth  of  a  grain  instead  of  in 
solution.  Calomel  or  grey  powder  sometimes 
acts  quite  well  from  the  conversion  of  minute 
portions  into  perchloride.  One-tenth  of  a  grain 
of  calomel  every  hour  or  the  third  of  a  grain  of 
grey  powder  is  sometimes  very  useful,  especially 
if  the  liver  be  somewhat  full  and  tender. 
Naphthol  is  useful  for  the  intestine  as  well 
as  for  the  stomach.  Salol  is  a  useful  intestinal 
disinfectant  in  doses  of  5  or  10  grs.  in  cachet 


360  ACTION  OF  DRUGS 

about  every  six  hours.  It  is  not  decomposed 
by  acids  but  is  decomposed  into  phenol  and 
salicylic  acid  by  alkalies,  and,  therefore,  should 
not  be  given  along  with  them.  If  the  motions 
are  very  offensive  the  odour  is  removed  perhaps 
more  quickly  by  naphthalin  than  by  any  other 
drug.  It  has,  however,  such  an  exceedingly 
disagreeable  and  penetrating  odour  that  almost 
the  only  way  to  give  it  is  to  have  it  put  up  in 
powders,  and  when  these  are  administered  a  large 
wafer  should  be  ordered  and  the  powder  should 
be  shaken  upon  it,  the  wafer  wrapped  up  and 
swallowed  at  once.  When  it  is  put  up  in  cachet 
the  odour  penetrates  through  the  cachet. 

Carminatives. — These  are  medicines  which 
tend  to  cause  evacuation  of  flatulence  either 
from  the  stomach  or  bowels.  The  most  com- 
monly used  are  essential  oils,  either  given  in 
small  quantities  in  the  form  of  a  pill  or  more 
frequently  dissolved  in  alcohol  or  water  in  the 
form  of  spirits  or  waters.  The  oils  used  for  this 
purpose  are  oleum  anethi,  anisi,  anthemidis, 
cajuputi,  carui,  caryophylli,  cinnamomi,  coria- 
nadri,  lavandulae,  menthae  piperitae,  menthae 
viridis,  myristicae,  pimentae,  rosmarini,  tere- 
binthinae.  The  spirits  are  spiritus  ammoniae 
aromaticus,  ammoniae  fcetidus,  aetheris,  aetheris 
co.,  anisi,  cajuputi,  camphorae,  chloroformi, 
cinnamomi,  juniperi,  juniperi  co.,  lavandulae, 
menthae  piperitae,  menthae  viridis,  myristicae, 
rosmarini.  The  waters  are  aqua  anethi,  anisi, 
camphorae,  carui,  chloroformi,  cinnamomi,  foene- 
culi,  menthae  piperitae,  menthae  viridis,  pimentae. 
In  addition  to  these  may  be  mentioned  the 


CARMINA  TIVES  36 1 

compound  tincture  of  cardamoms  and  the 
tincture  of  ginger.  Asafoetida  is  one  of  the 
most  powerful  carminatives  but  its  smell  is 
exceedingly  disagreeable.  In  the  form  of  the 
compound  galbanum  pill  it  is  sometimes  very 
useful  in  intestinal  flatulence.  When  there  is 
much  intestinal  distension  the  most  useful 
remedy  one  can  employ  is  asafoetida  in  the 
form  of  an  enema.  This  used  formerly  to  be 
made  by  rubbing  up  30  grs.  of  asafoetida  with 
4  ozs.  of  distilled  water,  but  is  more  easily  made 
by  adding  a  teaspoonful  of  tincture  of  asafoetida 
to  4  ozs.  of  thin  starch  paste. 

Dill  water  in  the  form  of  an  enema  sometimes 
brings  away  flatulence  rapidly  from  the  intes- 
tine. It  may  be  given  either  alone  in  doses  of 
4  ozs.  or  more,  or  made  up  to  8  or  even 
1 6  ozs.  with  thin  starch  paste  and  injected  at 
once.  The  most  common  of  all  carminatives 
is  probably  peppermint  water,  and  the  action 
of  this  is  frequently  assisted  considerably  by 
adding  to  half  a  wine  glassful  10  or  15  grs.  of 
bicarbonate  of  soda  or  about  half  a  teaspoonful 
of  aromatic  spirits  of  ammonia.  Such  a  dose 
may  be  repeated  if  necessary  every  quarter  of 
an  hour  until  relief  is  obtained.  Another 
favourite  remedy  is  the  syrup  or  tincture  of 
ginger  in  doses  of  half  a  teaspoonful  to  one  tea- 
spoonful  in  about  a  wineglassful  of  water  or 
five  to  ten  drops  of  the  strong  tincture,  or 
essence  as  it  is  usually  called,  given  in  the  same 
way.  Five  or  ten  drops  of  oil  of  cajuput  given 
in  the  same  way  or  simply  dropped  on  a  piece 
of  sugar  and  sucked  is  occasionally  very  useful. 

2  B 


362  ACTION  OF  DRUGS 

Another  pleasant  remedy  is  half  a  drachm  or  a 
drachm  of  compound  tincture  of  cardamoms  in 
an  ounce  of  chloroform  water,  and  the  addition 
of  10  minims  of  the  spirit  of  ether  assists  its 
action.  Dill  water  is  used  almost  universally 
as  a  carminative  for  infants,  and  is,  I  think,  too 
much  neglected  as  a  carminative  for  adults.  It 
may  either  be  given  alone  or  with  some  of  the  car- 
minative spirits  and  tinctures  already  mentioned. 
Adjuvants  to  Carminatives.  —  Sometimes 
flatulence  may  be  relieved  by  passing  a  long 
india-rubber  tube  well  up  the  rectum,  and,  if 
possible,  into  the  sigmoid  flexure.  For  this 
purpose  I  think  a  long  stomach-tube  is  better 
than  rectal  tubes,  or  even  catheters,  because  the 
rectal  tubes  usually  have  a  sharp  end  which  does 
not  find  its  way  so  well  up  the  bowel  as  the 
blunt  end  of  the  stomach-tube.  A  large  tube 
is  frequently  more  easy  to  pass  than  a  small 
one,  as  the  small  ones  double  up  and  become 
kinked  in  the  rectum.  The  accumulation  of 
gas  in  the  intestine  is  frequently  due,  in  part, 
at  least,  to  weakened  expulsive  power  of  the 
muscular  wall  of  the  intestine.  It  has  been 
found  that  such  paresis  of  the  intestine,  a 
condition  which  very  commonly  comes  on  and 
gives  rise  to  abdominal  operations,  can  be 
relieved  or  removed  by  the  use  of  pituitary 
body,  and  this  can  be  given  either  by  the 
mouth  or  perhaps  better  by  the  injection  of  "J\ 
to  15  minims  of  a  20  per  cent,  extract.  This  is 
best  injected  into  the  muscles,  as  when  injected 
hypodermically  it  may  cause  sloughing  of  the 
skin  and  vaso-motor  constriction. 


NARCOTICS  363 

Narcotics.  —  One  of  the  most  distressing 
symptoms  in  various  diseases  of  the  heart  and 
vessels  is  sleeplessness.  Sleep  appears  to  depend 
upon  a  quiescent  condition  of  the  cerebral  vessels, 
and  may  be  brought  about  by  the  action  of  such 
drugs  as  lessen  their  functional  activity  even 
though  the  cerebral  circulation  be  unchanged. 
According  to  Bouchard,9  the  normal  alternation 
of  sleep  and  waking  is  due  to  the  formation  in 
the  body  of  certain  substances  which  could 
hardly  be  called  toxins  but  may  be  termed 
leucomaines.  Those  formed  during  the  day 
have  a  soporific  action,  so  that  at  night  their 
accumulation  tends  to  produce  sleep.  During 
night  these  narcotic  substances  are  eliminated 
and  stimulating  substances  are  formed,  so  that 
by-and-by  the  narcotic  action  passes  off  and 
the  stimulant  action  prevails,  so  that  the  person 
awakes.  Amongst  the  narcotic  products  formed 
in  the  day  is  possibly  lactic  acid  or  lactates, 
which  are  the  products  of  muscular  waste.  But 
these  are  certainly  not  the  only  ones.  The  con- 
dition of  the  nerve  cells  depends  very  much  upon 
the  circulation.  Thus  it  was  shown  by  Fried- 
lander10  that  when  the  rabbit  has  received  a 
dose  of  isopropyl  alcohol  it  falls  asleep  at 
once  when  its  head  is  held  up  and  the  circula- 
tion is  lessened,  but  awakes  at  once  when  its 
head  is  lowered,  so  that  the  circulation  in  the 
brain  is  increased.  In  man,  Durham  n  observed 
that  the  brain  became  anaemic  during  sleep  and 
vascular  on  awaking.  The  circulation  of  blood 
in  the  brain  is  probably  regulated  by  the  con- 
tractile power  of  the  carotids  and  their  branches. 


364  ACTION  OF  DRUGS 

If  the  carotids  are  sclerosed  so  as  to  lose  their 
contractile  power,  sleeplessness  may  occur  as 
a  consequence,  and  in  one  case  of  persistent 
insomnia  I  have  seen  sleep  become  restored 
when  the  vessels  became  less  rigid  from  the 
combined  action  of  local  massage  and  the  use 
of  potassium  iodide.  Where  the  tension  is 
very  high  the  blood  tends  to  pour  through  the 
carotids  even  in  spite  of  their  contraction,  and 
thus  people  suffering  from  high  tension  are  liable 
to  be  sleepless.  A  similar  condition  occurs  in 
people  with  deficient  vaso-motor  power  in  whom 
the  blood-pressure  may  be  low,  but  the  carotids 
are  deficient  in  contractile  power,  and  thus  sleep- 
lessness may  be  associated  with  high  tension 
or  with  low  tension.  •  When  the  heart's  action 
is  excited  by  high  temperature,  as  in  fever  or 
by  the  effect  of  drugs  such  as  caffeine,  the 
circulation  through  the  brain  is  increased  and 
insomnia  results.  Sixty  years  ago  almost  the 
only  soporific  known  was  opium,  and  in  adminis- 
tering this  physicians  recognised  the  importance 
of  circulation,  because  if  the  circulation  was 
quiet  opium  was  given  alone,  but  if  fever  were 
present  at  the  same  time  it  was  usually  combined 
with  tartar  emetic.  In  one  preparation,  Dover's 
powder,  which  was  greatly  in  vogue,  the  tartar 
emetic  was  replaced  by  ipecacuanha,  and  this 
still  remains  an  exceedingly  good  remedy, 
because  one  of  the  dangers  that  is  usually 
apprehended  from  opium  is  its  depressing  action 
on  the  respiratory  centre,  and  this  is  counter- 
acted to  a  great  extent  at  least  by  the  ipecacu- 
anha, which  has  a  stimulant  effect  upon  this 


OPIUM  365 

centre.  In  cases  where  the  kidneys  are  seriously 
diseased  so  that  there  is  little  power  of  excretion, 
small  doses  of  opium  sometimes  produce  un- 
expectedly powerful  results,  and  a  dose  which 
would  ordinarily  be  perfectly  safe  would  be 
followed  by  fatal  consequences.  The  cases  in 
which  this  occurs  are  those  in  which  the  excre- 
tory power  is  lessened,  but  the  mere  occurrence 
of  albumen  in  the  urine  in  a  case  of  mitral 
disease  is  not  to  be  regarded  as  a  contra-indica- 
tion  for  opium. 


LITERATURE. 

1  Ludwig,    Wagner's  Hand-worterbuch  der  Physiologic, 

1884,  Bd.  ii.,  p.  628  et  seq. 

2  Bowman,  Phil.  Trans.,  1842,  vol.  cxxxii.,  p.  57. 

3  Meyer  and  Gottlieb,  Exper.  Pharmakologie,  1910,  p. 

297. 

4  Ibid.,  p.  298. 

5  Fleckseder,  unpublished  research  ;  -vide   Meyer  and 

Gottlieb,  loc.  tit.,  p.  299. 

6  Locke,  Practitioner,  1886,  vol.  xxxvii.,  p.  170. 

~  Metchnikoff,   The  Prolongation  of  Life,  trans,  by  P. 
Chalmers  Mitchell  (London  :  Heinemann,  1907). 

8  For  literature,  vide  Martindale  and  Westcott,  Ex:ra 

Pharmacopeia,  I5th  ed.,  1912,  vol.  i.,  p.  45  et  seq. 

9  Bouchard,  Cotnptes  rend.,  1886,  vol.  cii.,  pp.  669,  727, 


10  Friedlander,    Uber  den    Isopropyl   Alcohol,   Dissert., 

Berlin,  1888. 

11  Durham,  Guy  's  Hospital  Reports,  1860,  vol.  vi.,  p.  149  ; 

Psychological  Journal,  vol.  v.,  p.  74  et  seq.;  Brit. 
and  For.  Med.  Chir.  Rev.,  1861,  vol.  xxvii.,  pp.  234 
and  332. 


CHAPTER   XVI 

TREATMENT   OF  ACUTE   HEART    DISEASE 

Treatment  of  Acute  Heart  Disease — General  Rules- 
Acute  Rheumatism  —  Microbic  Infection  —  Rest  — 
Clothing — Sponging  —  Diet — Drinks — Stimulants — 
Flatulence  —  Medicines — Elimination — Local  Appli- 
cations— Poultices  —  Icebags — Leeches — Treatment 
of  Convalescence. 

IN  the  treatment  of  all  cases  of  heart  disease, 
whether  acute  or  chronic,  it  has  always  to  be 
borne  in  mind  that  there  is  a  natural  tendency 
to  recover,  and  that  this  tendency  should  be 
assisted  to  the  utmost  by  attending  to 

1.  Rest, 

2.  Nutrition, 

3.  Elimination. 

Rest  to  the  heart  is  of  the  utmost  importance, 
but  it  must  not  be  forgotten  that  in  the  case  of 
the  heart,  like  that  of  a  sprained  ankle,  too 
much  rest  may  interfere  with  the  nutrition. 
The  nutrition  of  the  heart  depends  partly  upon 
its  action,  partly  upon  the  condition  of  its  vessels, 
and  partly  upon  the  nature  of  the  blood  with 
which  it  is  supplied.  In  acute  conditions  there 
is  a  tendency  to  over -action  of  the  heart, 
and  therefore  rest  should  be  given  to  the 

866 


ACUTE  CARDIAC  DISEASES  367 

utmost  extent ;  but  in  chronic  conditions  a 
certain  amount  of  exercise  is  advisable,  both  as 
increasing  the  supply  of  blood  to  the  heart  in 
the  manner  already  described  (p.  155),  and  by 
its  action  on  the  other  parts  of  the  body  increas- 
ing digestion,  absorption,  and  elimination  of 
waste.  In  many  cases  of  heart  disease  attention 
to  the  digestion  and  elimination  is  of  even  more 
importance  than  the  use  of  remedies  which  will 
act  directly  upon  the  heart. 

Acute  Cardiac  Diseases.— A  few  patients 
die  of  acute  myocarditis,  endocarditis,  or  peri- 
carditis, but  the  great  majority  of  all  cases  of 
organic  heart  disease  do  not  die  when  first 
attacked  but  after  a  more  or  less  prolonged 
period,  sometimes  lasting  for  many  years,  from 
the  consequences  of  valvular  disease  occurring 
during  such  an  attack.  Endocarditis,  peri- 
carditis, and  myocarditis  frequently  occur  in 
the  course  of  rheumatic  fever  or  acute  infective 
diseases,  and  it  is,  therefore,  most  important  to 
watch  for  the  first  approach  of  a  cardiac  affection 
and  take  measures  to  prevent  injurious  conse- 
quences. When  the  first  sound  of  the  heart 
becomes  weak  or  imperceptible,  or  the  pulse 
begins  to  get  exceedingly  feeble,  rapid  or  irregu- 
lar, suspicion  is  at  once  directed  to  the  heart,  and 
sometimes  the  thermometer  may  be  most  useful 
in  detecting  the  mischief.  When  the  tempera- 
ture is  taken,  as  is  often  done,  only  night  and 
morning,  a  deceptive  record  may  be  obtained, 
because  it  may  appear  perfectly  normal ;  but 
in  endocarditis  the  temperature  frequently 
shoots  up  some  time  during  the  day,  and 


368  TREA  TMENT  OF  ACUTE  HEART  DISEASE 

if  a  four-hour  record  is  taken  this  may  be 
detected.1 

Cardiac  disease  certainly  seems  to  be  greatly 
on  the  increase,  but  how  far  this  is  due  to  the 
increased  power  of  detection,  owing  to  increased 
medical  training  and  to  the  improved  use  of 
diagnostic  methods,  and  how  far  to  actual  in- 
crease in  the  number  of  cases  it  is  hard  to  say. 

It  is  quite  possible,  however,  that  the 
difference  in  the  treatment  of  rheumatic 
disease  fifty  years  ago  and  now  may  be 
responsible  for  the  increased  amount  of  cardiac 
mischief.  Formerly  a  case  of  rheumatic  fever 
was  treated  by  alkalies,  usually  in  the  form  of 
citrate  of  potash  and  by  blisters  over  the 
affected  joints,  but  the  course  of  the  disease 
was  slow  and  the  enforced  rest  in  bed  was 
necessarily  long.  Nowadays  by  treatment  with 
large  doses  of  salicin  compounds,  the  pain 
in  the  joints  quickly  disappears,  and  the  patient 
is  often  able  to  get  about  in  a  few  days  instead 
of  weeks  or  months.  It  is  by  no  means 
improbable  that  the  strain  which  rising  so 
soon  produces  upon  the  heart,  enfeebled  by  the 
disease  and  perhaps  also  to  some  extent  by 
the  remedies  employed,  may  be  responsible 
for  a  good  deal  of  cardiac  mischief.  Certainly 
cases  of  influenza  seem  to  bear  out  this  opinion 
very  strongly,  because  I  have  frequently  noticed 
that  patients  have  complained  of  symptoms  of 
feeble  circulation  which  came  on  after  influenza 
and  have  lasted  two,  three,  or  even  more 
years,  and  these  symptoms  have  come  on  not 
unfrequently  after  mild  attacks  of  influenza  in 


REST  IN  ACUTE  DISEASES  369 

which  the  patient  was  either  not  confined  to 
bed  at  all  or  only  for  a  short  time.  I  think 
it  quite  likely  that  if  the  voluntary  muscles 
were  not  also  enfeebled  by  an  attack  of  typhoid, 
this  disease  would  be  followed  by  cardiac  symp- 
toms more  frequently  than  it  is  -at  present. 

As  Caton2  has  well  pointed  out,  cardiac  excite- 
ment while  endocarditis  is  present  is  likely  to 
hammer  the  pathogenic  microbes  into  the 
valves  and  thus  lead  to  valvular  disease.  It 
is,  therefore,  of  the  utmost  importance  that 
the  patient  should  be  kept  at  absolute  rest. 
The  rules  for  this  have  already  been  given 
(vide  p.  232). 

Rest. — Any  excitement  will  tend  to  quicken 
the  heart's  action  and  raise  the  blood-pressure, 
and,  therefore,  excitement  of  every  kind  ought 
to  be  most  studiously  avoided.  Even  pleasur- 
able excitement,  such  as  seeing  friends,  must 
be  strictly. limited,  and  if  friends  are  allowed 
to  visit  the  patient  they  should  be  enjoined 
not  to  let  the  patient  talk,  but  do  most  of  the 
talking  themselves  and  to  avoid  carefully  any 
subject  likely  to  lead  to  excitement.  The 
great  difficulty  which  one  has  often  to  meet 
with  is  that  of  keeping  the  patient  sufficiently 
long,  in  bed,  because  the  modern  treatment 
by  salicylates  lessens  pain  so  much  more 
quickly  than  the  old  treatment  that  it  is  much 
more  difficult  to  insure  prolonged  rest  than 
it  used  to  be  formerly.  Caton  recommends, 
and  I  think  rightly,  that  rest  should  be  con- 
tinued for  three  months  in  order  to  avoid  risk 
of  relapse  and  consequent  valvular  mischief. 


370  TREATMENT  OF  ACUTE  HEART  DISEASE 

Clothing. — Another  important  point  is  the 
prevention  of  chills  to  any  part  of  the  body 
which  would  raise  the  tension  and  thus  cause 
mischief.  In  order  to  prevent  this  it  is 
customary  to  let  patients  with  rheumatic 
fever  lie  between  blankets  instead  of  between 
cotton  or  linen  sheets.  Instead  of  this  Caton 3 
recommends  a  long  flannel  nightgown  which 
will  completely  envelop  the  body  and  limbs 
and  prevent  any  chance  of  chill.  As  patients 
suffering  from  rheumatic  fever  frequently 
perspire  very  freely,  so  that  their  nightgowns 
become  wet  and  require  to  be  changed,  it  is 
advisable  to  have  them  made  to  open  the 
whole  length  of  the  back  and  be  fastened 
either  with  tape  or  soft  flat  buttons,  so  that 
they  can  be  adjusted  or  removed  much  more 
easily  than  when  they  are  open  in  front. 

A  urinal  and  bed-pan  should  be  used  instead 
of  a  commode,  which  should  only  be  employed 
when  absolutely  necessary,  and  then  with  the 
precautions  already  given  (p.  236). 

Sponging. — The  perspiration  tends  to  make 
the  patients  sticky  and  uncomfortable,  and  so 
they  require  to  be  sponged  once  or  twice  a  day, 
or  even  oftener.  In  doing  this  the  patient 
should  be  disturbed  as  little  as  possible,  and 
should  be  exposed  as  little  as  possible,  a  small 
part  of  the  surface  being  sponged  at  once,  then 
dried  and  covered  up,  and  the  nurse  should  take 
care  that  the  windows  are  shut,  and  that  no 
draught  should  blow  upon  the  patient  during 
the  process.  It  is  important  that  the  tempera- 
ture of  the  patient  should  be  kept  as  far  as 


SPONGING— BEDS  371 

possible  from  rising  high,  because  the  high 
temperature  of  the  blood  causes  increased 
action  of  the  heart,  and  this,  of  course,  is 
injurious.  One  of  the  best  means  of  keeping 
the  temperature  down  is  to  sponge  the  whole 
body  and  limbs  with  warm  water  as  hot  as  can 
be  comfortably  borne,  and  then  instead  of  drying 
the  surface  simply  to  dab  off  the  loose  water 
and  then  cover  the  patient  by  a  cradle  over 
which  is  laid  a  single  blanket.  The  water  upon 
the  surface  of  the  patient's  skin  thus  evaporates 
and  tends  to  reduce  the  temperature  without 
chilling  him.  If  the  temperature  is  very  high  the 
end  of  the  cradle  may  be  left  uncovered,  so  that 
the  air  may  enter  more  quickly  and  evaporation 
go  on  more  rapidly.  If  the  joints  are  very 
painful  they  ought  to  be  protected  by  a  cradle, 
and  if  they  are  wrapped  in  cotton-wool,  this 
should  be  kept  in  place  by  several  short 
bandages  tied  in  front,  and  not  by  one  long 
one  passed  round  the  limb. 

While  a  hard  bed  is  most  uncomfortable  and 
likely  to  give  the  patient  pain  and  increased 
restlessness,  too  soft  a  bed  is  also  bad,  and  I 
have  seen  a  patient  who  was  lying  in  great  dis- 
comfort on  a  soft  feather-bed  obtain  much 
comfort  when  he  was  put  on  a  hard  mattress 
on  top  of  the  feather-bed.  This  gave  the 
requisite  softness  without  being  too  yield- 
ing. Some  patients  object  strongly  to  water- 
beds  or  water-pillows,  both  because  of  the 
difficulty  of  keeping  these  at  a  proper  tempera- 
ture and  because  of  the  discomfort  they  feel  at 
the  oscillation  of  the  water  on  the  least  move- 


37*  TREATMENT  OF  ACUTE  HEART  DISEASE 

ment.  Both  of  these  disadvantages  are 
obviated  by  using  air  -  pillows  or  air  -  beds 
instead  of  water-beds. 

Diet. — During  the  febrile  condition  the  diet 
should  be  chiefly  milk  alone,  or  if  it  is  not  well 
borne  undiluted,  it  may  be  mixed  with  Vichy 
water,  potash  water,  or  soda  water.  If  there 
is  the  least  tendency  to  flatulence  a  simple 
solution  of  bicarbonate  of  soda  or  bicarbonate 
of  potash  in  water  may  be  used  instead.  Ten 
or  fifteen  grains  of  common  salt  have  been 
recommended  as  an  addition  to  a  pint  and  a 
half  of  milk.  The  proprietary  foods,  of  which 
there  are  a  great  number,  may  be  used  either 
along  with,  or  alternately  with  milk  if  they  are 
found  to  suit.  Sometimes  they  tend  to  give 
rise  to  more  flatulence  than  the  milk  alone  does, 
but,  on  the  other  hand,  they  are  sometimes 
better  digested  than  the  milk,  as  they  have  less 
tendency  to  form  curds  in  the  stomach.  When 
the  milk  treatment  has  to  be  continued  long,  it 
becomes  very  irksome  to  the  patient,  and  this 
can  be  lessened  by  flavouring  the  milk  with  tea, 
coffee,  or  with  chocolate.  The  advantage  of 
this,  of  course,  is  that  it  is  pleasanter  to  the 
patient,  but  care  must  be  taken  that  the  admix- 
ture of  these  substances  with  the  milk  does  not 
stimulate  the  heart  too  much.  Rusk,  biscuit,  or 
bread  with  a  little  butter  may  be  given  along 
with  the  milk  if  the  patient  desires  it,  but  they 
should  be  eaten  slowly  and  well  broken  up  in 
the  mouth.  To  vary  the  milk,  even  beef-tea, 
mutton-tea,  or  chicken-tea  may  be  given 
alone,  or  with  rusk,  or  bread  in  the  way  just 


VIET— BRINKS—  STIMULANTS          373 

mentioned.  These  meat-teas  should  not  be 
strong,  and  if  made  from  meat  extracts  with 
hot  water  they  should  not  be  more  than  a  pale 
straw  colour. 

When  the  febrile  condition  disappears  the  diet 
may  be  increased,  giving  fish,  eggs,  boiled  or 
poached  or  omelette,  and  meat  jellies  if  the  patient 
likes  them.  Care  should  be  taken  to  increase 
the  diet  very  gradually  and  at  once  restrict  it 
again  if  the  increase  seems  to  be  doing  harm. 

Drinks.  —  When  there  is  much  thirst  the 
diluted  milk  is  both  meat  and  drink,  and  if  the 
patient  requires  more  liquid,  perhaps  there  is 
nothing  better  than  the  old-fashioned  imperial 
drink.  There  are  a  good  many  different  ways 
of  making  it;  the  essence  of  it  is  I  to 
2  drachms  of  acid  potassium  tartrate  to  an 
imperial  pint  of  water.  This  is  flavoured  with 
syrup  of  lemon  or  lemon  juice  or  syrup  or  sugar 
only.  My  own  preference  is  for  the  formula 
used  at  St  Bartholomew's  Hospital  of  a  tea- 
spoonful  of  potassium  acid  tartrate  with  half  a 
fresh  lemon  and  sugar  to  taste,  boiling  water 
20  ozs.  This  should  be  occasionally  stirred 
until  cold  and  then  strained. 

Stimulants. — As  a  rule  patients  are  better 
without  stimulant,  but  if  the  pulse  is  flagging  or 
digestion  is  badly  performed,  whisky  or  brandy 
may  be  given  as  necessary,  in  quantities  varying 
from  i  to  6  ozs.  in  the  twenty-four  hours.  It  is 
best  to  put  the  quantity  into  a  measured  bottle 
every  twenty -four  hours,  so  that  the  exact 
amount  used  can  be  at  once  observed.  It  is 
best  not  to  give  a  large  dose  at  once,  but  rather 


374  TREA  TMENT  OF  ACUTE  H$ART  DISEASE 

to  give  it  frequently  in  small  quantity,  I  to  2 
drachms  along  with  the  milk. 

Flatulence. — The  effect  of  flatulence  upon 
the  heart  is  sometimes  very  distressing  and 
must  be  avoided  as  far  as  possible.  Milk  does 
not  give  rise  to  flatulence  to  the  same  extent  as 
carbohydrates  do,  and  therefore  if  the  flatulence 
be  distressing  it  is  advisable  to  put  the  patient, 
for  a  short  time  at  least,  upon  an  entirely  milk 
diet.  If  solids  are  given  at  all  it  is  best  to 
give  them  separately  from  the  liquids  and  allow 
at  least  an  interval  of  an  hour  between  them. 
The  production  of  gas  in  the  stomach  and 
intestines  may  be  lessened  by  antiseptics,  and 
when  present  its  expulsion  may  be  attained  by 
carminatives  (p.  360). 

Medicines. — Salicylate  of  soda  is  the  remedy 
par  excellence  for  acute  rheumatism.  The 
natural  salicylate  is  better  than  the  artificial. 
It  should  be  given  in  doses  of  10  to  15  grs. 
every  four  hours,  or  if  the  temperature  be  high 
and  the  pain  great,  every  three  hours,  or  even 
more  frequently.  Some  patients  greatly  dislike 
the  taste  of  it,  but  its  somewhat  sweet  and 
mawkish  taste  may  be  disguised  by  a  little 
tincture  of  orange  peel  or  liquid  extract  of 
liquorice  or  other  flavouring  agents.  When 
singing  comes  on  in  the  ears  the  dose  should 
be  lessened  or  omitted  once  or  twice  altogether. 
If  it  seems  to  be  exerting  too  depressing  an 
effect  upon  the  pulse  half  a  drachm  to  a  drachm 
of  aromatic  spirits  of  ammonia  may  be  added 
to  each  dose,  and  if  there  are  any  indications  of 
cardiac  failure  five  to  seven  minims  of  tincture 


MEDICINES— ELIMINATION  375 

of  nux  vomica  or  liquor  strychninae,  and  5 
minims  of  tincture  of  digitalis  or  more  may  be 
added  to  each  dose  of  the  salicylate.  If  a  more 
rapid  action  is  desired  the  thirtieth  of  a  grain 
of  sulphate  of  strychnine  may  be  used  as  a 
hypodermic  injection. 

As  the  temperature  falls  and  the  pain  subsides 
the  dose  of  salicylate  may  be  gradually  lessened 
to  10,  7\  or  5  grs.  every  six  or  eight  hours, 
but  it  is  well  to  keep  it  up  in  small  quantities 
for  a  week  or  ten  days  after  the  symptoms  have 
quite  subsided,  and  if  any  indication  of  any 
relapse  should  occur  larger  and  more  frequent 
doses  should  be  given  again  at  once.  ;r 

Elimination. — It  is  important  that  the  intes- 
tinal canal  should  be  kept  clear  so  as  to  avoid 
any  accumulation  whatever,  and  this  may  be 
effected  by  some  preparation  of  cascara  or  senna ; 
but  it  is  advisable  also  to  stimulate  the  liver, 
and  for  this  purpose  I  or  2  grs.  of  calomel  may 
be  given  on  alternate  nights  and  followed  by  an 
effervescent  saline  in  the  morning.  It  some- 
times happens  that  when  patients  are  lying  in 
bed  salines  do  not  act  well,  and  if  so,  the  salines 
must  be  mixed  with  some  other  purgative 
such  as  the  Mistura  Sennae  Composita  of  the 
Pharmacopoeia. 

Local  Applications. — Before  the  introduction 
of  salicylates  the  swollen  and  painful  joints  in 
acute  rheumatism  were  frequently  treated  with 
the  application  of  a  strip  of  blister,  about  an  inch 
or  an  inch  and  a  half  broad,  round  the  limb,  just 
above  and  below  the  joint,  and  this  treatment 
appears  to  be  to  some  extent  one  of  serothera- 


376  TREA  TMENT  OF  A  CUTE  HEART  DISEA  SE 

peutics  because  it  had  the  effect  of  increasing 
the  alkalinity  of  the  urine. 

Endocarditis. — In  a  case  of  rheumatic  fever 
if  the  pulse  becomes  unduly  quick  or  irregular 
and  the  temperature  rises  without  any  apparent 
reason  endocarditis  may  be  suspected,  and 
dilatation  or  the  presence  of  a  murmur  at  one 
of  the  orifices  should  be  looked  for.  Should 
this  occur  the  precautions  already  mentioned 
regarding  rest  should  be  enforced  still  more 
rigidly,  and  if  there  is  distress  over  the  heart 
or  palpitation,  ice-bags  may  be  employed  and 
warm  sponging  over  the  rest  of  the  body  in  the 
manner  already  described.  If  the  ice-bag  is 
applied  directly  to  the  skin  it  is  apt  to  induce 
a  feeling  of  chill,  which  is  avoided  by  covering 
it  with  flannel.  If  the  pain  is  acute  the  applica- 
tion of  half  a  dozen  leeches  over  the  cardiac 
area  is  probably  the  best  means  of  removing 
it.  Dover's  powder  in  10  gr.  doses  has  the 
double  action  of  relieving  pain  and  tending  to 
lower  the  temperature ;  but  if  the  pain  is  very 
acute,  a  hypodermic  injection  of  £th  to  Jrd  of  a 
grain  of  morphine  will  give  relief  more  quickly. 
If  the  pulse  becomes  very  small  or  irregular 
and  the  heart  shows  signs  of  rapid  dilatation, 
digitalis  may  be  given  in  doses  of  5  minims  every 
two  or  three  hours,  its  action  being  carefully 
watched.  If  the  temperature  tends  to  rise  much 
in  spite  of  sponging  as  already  recommended 
and  the  application  of  the  ice-bag,  phenacetin 
in  doses  of  3  to  10  grs.  may  be  given,  or 
5  grs.  of  antifebrin.  I  think  phenacetin  is 
rather  less  depressing  than  either  antipyrin  or 


ENDOCARDITIS— PERICARDITIS        377 

antifebrin,  and  so  is  to  be  preferred,  and  along 
with  it  cardiac  stimulants  such  as  ether  and 
ammonia,  or  strychnine,  either  by  the  mouth  or 
subcutaneously,  may  be  employed  as  seems 
necessary. 

Pericarditis. — When  a  friction  over  the  heart 
indicates  commencing  pericarditis  the  treat- 
ment is  the  same  as  for  endocarditis.  Diminu- 
tion or  absence  of  the  apex  beat  with  increased 
dulness,  especially  towards  the  right,  indicates  the 
beginning  of  pericardial  effusion,  and  a  series  of 
small  blisters  about  the  size  of  a  shilling  should 
be  applied  over  the  precordial  region.  Four 
or  five  may  be  employed  at  once  and  a  similar 
number  over  fresh  pieces  of  skin  after  a  couple  of 
days.  The  pain  may  sometimes  be  removed  by 
salicylic  ionization.4  If  the  effusion  is  not  dis- 
appearing iodide  of  potassium  in  5  or  10  gr. 
doses  and  digitalis  may  also  be  given  to  promote 
absorption  and  increase  the  action  of  the  kidneys 
Any  of  the  preparations  of  digitalis  may  be  used, 
but  personally  I  have  a  prejudice,  possibly  un- 
founded, in  favour  of  the  infusion  in  doses  of  I  to 
2  drachms.  Should  the  effusion  continue  to  in- 
crease and  interfere  with  the  action  of  the  heart, 
causing  the  pulse  to  become  small  and  very 
quick,  the  breathing  difficult,  and  the  face 
dusky,  it  is  advisable  to  remove  the  effusion  either 
by  aspiration  or  by  incision.  An  aspirating 
needle  may  be  introduced  in  the  fourth  or  fifth 
interspace  about  the  nipple  line.  Before  doing 
this  the  cardiac  dulness  should  be  carefully 
mapped  out  to  make  sure  that  it  is  due  to 
effusion  and  not  simply  to  cardiac  dilatation. 

2  C 


378  TREA  TMENT  OF  ACUTE  HEART  DISEASE 

Septic  Endocarditis  and  Pericarditis. — Al- 
though acute  rheumatism  is  the  most  common 
cause  of  heart  disease,  yet  both  endocarditis 
and  pericarditis  may  occur  from  invasion  of  the 
blood  by  various  micro-organisms,  and  strepto- 
cocci, pneumococci,  staphylococci,  gonococci,  and 
various  species  of  bacilli  all  give  rise  to  acute 
heart  affections. 

Apparently  these  enter  very  frequently  from 
the  tonsils.  In  patients  who  suffer  much  from 
tonsillitis  it  is  advisable  to  have  the  tonsils 
removed.  Some  of  these  cases  are  most  insidi- 
ous in  their  onset,  and  are  only  discovered  almost 
by  accident  on  examination  of  the  heart  after  a 
sudden  rigor  or  fainting  fit.  In  such  cases  the 
treatment  is  absolute  quiet  in  the  manner 
already  described,  but  the  urine  should  be  care- 
fully examined  for  micro-organisms,  and  if  none 
be  found  in  it  the  secretion  from  the  tonsils  or 
sputum  should  also  be  examined.  Failing  this, 
the  blood  should  be  examined  carefully  for  micro- 
organisms. Ten  cubic  centimetres  are  wanted 
at  least  for  this  purpose,  and  should  be  taken  by 
a  sterile  instrument  directly  from  the  vein. 
Should  any  organisms  be  found,  a  vaccine  ought 
to  be  made  and  injected  in  proper  quantities, 
and  at  proper  intervals,  to  be  determined  by  the 
severity  of  the  case.  Medicines,  as  a  rule,  are  of 
very  little  use,  but  I  have  seen  some  cases 
recover  under  the  use  of  15  to  20  grs.  of  benzoate 
of  soda  every  two  hours.  I  have  also  seen 
recoveries  from  oil  of  eucalyptus.  The  average 
dose  of  this  is  given  in  the  United  States 
Pharmacopoeia  as  I  to  8  minims.  The 


TREATMENT  OF  CONVALESCENCE    379 

average  given  in  the  English  textbooks  is 
much  less,  but  unless  the  larger  dose  is  given 
it  will  be  of  little  avail,  and  it  may  be  given  in 
emulsion  with  mucilage. 

Treatment  of  Convalescence  from  Acute 
Heart  Disease.  —  When  the  temperature  has 
become  quite  normal  and  the  pains  are  all 
gone,  the  dieting  may  be  increased  carefully  by 
allowing  a  little  fish,  such  as  whiting  or  sole. 
If  this  agrees,  haddock  or  cod  may  be  given. 
These  fish  are  best  boiled,  but  if  they  are  agree- 
ing well  the  sole  may  be  given  fried,  great 
care  being  taken  to  remove  all  the  skin  before 
it  is  eaten.  The  breast  of  chicken  may  then  be 
given,  and  in  a  few  days  more,  some  minced  meat 
may  be  tried,  gradually  proceeding  to  a  small 
cutlet  or  slice  of  mutton,  and  later  on  to  beef. 
Along  with  this  may  be  given  at  first  toast,  and 
afterwards  some  potato  well  boiled  or  mashed. 
Green  vegetables  have  a  tendency  to  cause 
flatulence,  but  at  the  same  time  they  are  useful, 
both  in  varying  the  diet  and  having  a  laxative 
action  upon  the  bowels.  Mashed  turnips,  mashed 
carrots,  spinach,  cauliflower,  and  brussels  sprouts, 
or  asparagus,  if  in  season.  Peas,  even  though 
green  and  quite  soft,  must  be  carefully  chewed, 
for  there  is  a  tendency  to  swallow  them  whole, 
and  then  they  are  apt  to  cause  flatulence. 

LITERATURE. 

1  Lauder  Brunton,  Edin.  Med.Journ.,  1897,  May  ist,  466. 

2  R.  Caton,  The  Prevention  of  Valvular  Disease  of  the 

Heart  (C.  J.  Clay  &  Sons,  London,  1900,  p.  12). 

3  Ibid.,  p.  35. 

4  Mackintosh,  Brit.  Med.  Joum.,  1913,  vol.  ii.,  p.  1205. 


CHAPTER  XVII 


The  Heart  is  not  an  Isolated  Organ — Its  Efficiency 
Depends  on  Good  Quality  of  Blood — Requirements 
for  this  —  Digestion  —  Assimilation— Metabolism  — 
Excretion  —  Mastication  —  Gastric  Digestion  —  Ex- 
ternal and  Internal  Secretions — Autocoid  Substances 
— Hormones  —  Chalones  —  Intestinal  Digestion  — 
Absorption  and  Assimilation — Autointoxication — 
Action  of  the  Liver  —  Defecation  —  Metabolism  — 
Exercise  —  Excretion  —  Bowels — Liver—  Kidneys  — 
Skin. 

General  Principles  of  Treatment  in  Chronic 
Heart  Disease. — In  acute  heart  disease  the 
duration  of  the  disease  is  brief,  and  the  atten- 
tion of  the  physician  is  directed  chiefly  to  the 
organ  affected ;  but  the  case  is  different  with 
other  forms,  which  may  last  for  many  years. 
In  the  treatment  of  such  cardiac  diseases 
whether  organic  or  functional,  it  must  always 
be  borne  in  mind  that  the  heart  is  not  an 
isolated  organ,  but  is  part  of  the  body,  and  that 
the  nutrition,  functional  activity,  and  efficiency 
of  the  heart  depend  upon  the  condition  of  the 
blood  which  it  has  to  drive  through  the  body 
(cf.  p.  151),  as  well  as  on  the  varying  activity  of 

880 


GENERAL  PRINCIPLES  381 

the  muscular  and  nervous  systems  which  it  is 
called  upon  to  meet.  The  condition  of  the 
blood  again  depends  upon  the  efficiency  with 
which  the  processes  of  digestion,  assimilation, 
tissue-metabolism,  and  excretion  by  the  bowels, 
kidneys,  and  skin  are  carried  on.  Tissue- 
metabolism  has,  undoubtedly,  a  great  deal  to 
do  with  the  condition  of  the  blood,  and  is 
especially  dependent  on  the  secretions  of  the 
ductless  glands  At  present  our  knowledge  of 
their  functions  and  of  the  action  and  reaction 
of  their  secretions  upon  each  other  is  still 
very  imperfect,  and  although  we  are  now 
beginning  to  use  the  dried  glands  or  their 
products  as  medicines  in  disorders  of  the  circu- 
lation, we  are  still  obliged,  at  present,  to  rely 
more  upon  the  older  remedies  for  promoting 
(i)  digestion,  (2)  assimilation,  and  (3)  excretion, 
than  upon  the  newer  ones  which  modify  tissue 
change.  When  an  inexperienced  man  begins 
driving  a  horse  and  finds  that  the  animal  is  not 
going  steadily  as  it  usually  would  do,  but  throws 
its  head  up  and  down,  or  jerks  uneasily  from 
side  to  side,  or  sometimes  goes  quickly  and 
sometimes  nearly  stops  altogether,  he  is  apt  to 
pull  at  the  reins  and  use  the  whip ;  while  an 
older  and  more  experienced  man  would  at  once 
ask  himself,  "  Why  does  the  animal  do  this  ? " 
He  would  look  at  the  horse's  mouth  and  see 
whether  the  bit  was  not  hurting  it,  whether  the 
harness  was  not  fretting  its  skin,  and  whether  it 
had  not  got  a  stone  in  its  shoe.  He  would  try 
to  remove  all  sources  of  annoyance  from  the 
animal  before  he  either  pulled  at  the  reins  or 


382       TREATMENT  IN  HEART  DISEASE 

used  the  whip.  In  the  same  way,  a  young 
physician  who  is  called  upon  to  treat  some 
irregularity  of  the  heart  is  apt  at  once  to  have 
recourse  to  digitalis,  strophanthus,  or  nux 
vomica  and  the  like,  but  one  with  more 
experience  would  ask  himself,  "Why  is  this 
heart  going  irregularly?"  and  he  would  very 
likely  find  that  the  irregularity  was  due  to 
excessive  acidity  in  the  stomach,  to  flatulence 
in  the  stomach  or  bowels,  or  to  some  imperfect 
action  of  the  liver  as  shown  by  tenderness  over 
that  organ,  with  perhaps  pale  stools  and  a 
slight  icteric  tinge  of  the  conjunctivas.  All 
these  he  would  try  to  put  right  before  having 
recourse  to  drugs  which  would  act  more  power- 
fully upon  the  heart,  and  in  most  cases  the 
result  would  be  more  satisfactory  than  if  he  had 
begun  at  once  with  the  latter  class  of  remedies. 
Digestion. — The  first  part  of  the  digestive 
processes  is  mastication,  and  a  great  many 
cases  of  dyspepsia  depend  either  upon  deficiency 
of  teeth  or  the  presence  of  decayed  teeth,  or 
on  too  great  hurry  in  swallowing  food,  so  that 
there  is  no  time  for  proper  mastication.  An 
imperfect  set  of  teeth  is  often  worse  than  no 
teeth  at  all,  because,  as  shown  in  the  diagram 
(Fig.  107),  the  remaining  teeth  simply  prevent 
the  jaws  from  meeting,  and  there  is  almost  no 
grinding  surface  at  all.  Where  this  is  the  case 
artificial  teeth  ought  to  be  put  in.  When  teeth 
are  decayed  they  ought  to  be  stopped  if  possible, 
as  the  decayed  cavity  forms  a  reservoir  for 
microbes  of  all  sorts,  which  tend  to  infect  the 
food  as  it  passes  from  the  mouth  into  the 


DIGESTION— MASTICATION  383 

stomach.  Pyorrhoea  is  another  common  cause 
of  infection  of  the  food,  and  not  only  so,  for  I 
have  seen  a  case  of  fatal  ulcerative  endocarditis 
where  I  felt  quite  sure  the  infective  microbes 
had  been  absorbed  from  the  alveoli  of  the  teeth. 
It  is  very  difficult  to  do  anything  with  this 
condition,  excepting  by  thorough  scaling  of  the 
teeth,  combined  with  vaccine  treatment,  or,  in 
very  advanced  cases,  by  extraction  of  the  teeth. 
Perhaps  the  simplest  method  of  treatment, 
which  can  be  employed  by  the  patient  himself, 


Fio.  107. — Defective  teeth,  showing  how  they  may  prevent  the  gums  from 
meeting,  without  presenting  any  grinding  surface. 

is  to  paint  the  gums  round  at  their  junction 
with  the  teeth  with  tincture  of  iodine,  or  to  wash 
the  mouth  frequently  with  a  solution  of  peroxide 
of  hydrogen.  The  tonsils  are  a  common  source 
of  infection,  and  if  there  is  any  tendency  to 
tonsillitis  they  may  be  painted  every  night,  or 
every  night  and  morning,  with  equal  parts  of 
glycerine  of  tannic  acid  and  tincture  of  iodine.  If 
very  large  and  subject  to  frequent  inflammation, 
they  ought  to  be  removed.  Hasty  mastication 
is  an  exceedingly  common  cause  of  dyspepsia, 
especially  in  busy  men  or  in  people  of  a  nervous 
temperament.  When  these  begin  to  think  of 
any  work  that  is  to  be  done  they  are  apt  to 


384     TREATMENT  IN  HEART  DISEASE 

swallow  their  food  without  thinking  what  they 
are  doing.  For  such  people  it  is  a  good  thing 
to  follow  the  rule  observed  by  the  late  Mr 
Gladstone,  I  believe  on  the  advice  of  the  late 
Sir  Andrew  Clark,  to  give  every  tooth  a  chance, 
and  bite  each  mouthful  of  meat  thirty-two  times, 
counting  the  bites.  The  advantage  of  such 
thorough  mastication  is  not  only  that  the  food 
is  more  finely  comminuted,  but  the  longer 
mastication  causes  a  greater  secretion  of  saliva. 
This  assists  digestion  both  directly  by  convert- 
ing starch  into  sugar,  and  also  indirectly  by 
stimulating  the  secretion  of  gastric  juice. 
Another  aid  to  thorough  mastication  is  afforded 
by  not  eating  and  drinking  at  the  same  time. 
Many  people  are  apt  to  chew  their  food  very 
imperfectly  and  wash  it  down  with  liquid,  either 
water,  tea,  coffee,  wine,  or  spirits,  during  the 
meal.  When  no  liquid  is  taken  with  the  meal, 
this  becomes  almost  impossible.  The  food 
must  then  be  broken  up  thoroughly  and  mixed 
with  saliva. 

One  great  rule  in  indigestion  of  all  sorts, 
therefore,  is  to  take  little  or  no  liquid  during 
meals. 

When  liquid  is  drunk  towards  the  end  of  a 
meal,  the  danger  of  imperfect  mastication  is 
lessened,  but  much  liquid  taken  at  this  time 
will  still  interfere  with  digestion  in  the  stomach, 
by  diluting  the  gastric  juice  and  so  weakening 
its  digestive  power. 

Of  course,  a  large  quantity  of  food  which  would 
distend  the  stomach  mechanically  should  be 
avoided ;  and,  if  required,  the  meals  should  be 


EATING  AND  DRINKING  385 

small  in  quantity  and  more  frequently  repeated. 
Articles  of  diet  that  tend  to  cause  flatulency, 
such  as  cabbage,  pastry,  and  sugar,  should  also 
be  avoided,  or  anything  else  that  seems  to  dis- 
agree with  the  patient 

As  Pawlow l  has  shown,  tasteless  and  unappe- 
tising food  does  not  stimulate  either  insalivation 
or  gastric  secretion,  whereas  tasty,  appetising 
food  will  do  both ;  so  the  manner  in  which  food 
is  cooked  and  presented  to  the  patient  is 
almost,  or  quite,  as  important  as  the  nature 
of  the  food. 

It  is  curious  to  notice  how  often  a  meal  of 
the  very  plainest  character  such  as  a  slice  of 
boiled  mutton  with  a  potato -or  piece  of  stale 
bread  eaten  at  home  will  cause  discomfort  and 
pain,  while  a  large  table  d'hote  dinner  can  be 
eaten  with  pleasure  and  impunity.  But,  while 
people  who  have  a  tendency  to  flatulence  or 
indigestion  should  take  little  or  no  liquid  with 
their  meals,  it  is  evident  that  as  the  body 
contains  so  much  water,  water  must  be  taken 
in  some  form  or  another  during  the  day.  The 
best  form  in  which  to  take  it  is  that  of  simple 
hot  water,  as  hot  as  can  comfortably  be  drunk, 
with  a  slice  of  lemon  floating  on  the  surface 
to  relieve  the  insipidity  of  the  hot  water  itself. 
The  water  should  not  be  drunk  in  large 
draughts,  but  should  be  slowly  sipped.  The 
best  time  for  taking  the  water  is  when  digestion 
in  the  stomach  is  finished,  that  is  to  say,  three 
or  four  hours  after  a  meal.  Thus,  if  breakfast 
be  taken  at  8,  some  hot  water  may  be  sipped 
between  u  and  12.  If  lunch  be  taken  at  I, 


386      TREATMENT  IN  HEART  DISEASE 

some  hot  water  may  be  sipped  between  4  and 
5.  At  this  time  the  water  may  be  either 
sipped  alone  or  it  may  be  slightly  flavoured 
with  tea,  or  the  water  may  be  sipped  first  and  a 
cup  of  ordinary  tea  drunk  afterwards.  The 
water  alone  is  best,  because  the  cup  of  tea  some- 
times gives  rise  to  acidity  and  flatulence ;  but 
its  refreshing  power  is  so  great  that  in  some 
cases  it  may  be  allowed,  and  if  so,  it  ought  to 
be  China  tea.  If  hot  water  or  tea  be  disliked, 
the  water  may  be  simply  flavoured  with  some 
kind  of  meat  extract ;  or  thin  broth,  julienne 
soup,  or  beef-,  mutton-,  or  chicken-tea  may  be 
substituted,  but  it  must  not  be  strong.  Water 
should  again  be  sipped  before  going  to  bed. 

Water  taken  in  this  way  not  only  supplies 
the  needs  of  the  body,  but  tends  to  wash  out 
the  contents  of  the  stomach  after  each  meal, 
so  that  no  food  is  left  behind  to  ferment. 
When  the  stomach  is  not  cleaned  out,  remnants 
of  food  are  apt  to  undergo  fermentation,  and 
the  portion  of  each  meal  that  is  left  behind 
tends  to  start  fermentation  in  the  next  meal, 
so  that  a  state  of  indigestion  is  set  up  which 
may  remain  for  a  length  of  time. 

Gastric  Digestion. — In  the  stomach,  carbo- 
hydrates such  as  starches  may  still  undergo  a 
certain  amount  of  conversion  into  sugar  by  the 
saliva  with  which  they  have  been  mixed  in  the 
mouth,  but  as  the  acid  gastric  juice  accumulates, 
the  action  of  the  saliva  diminishes,  and  in  the 
stomach  it  is  chiefly  the  digestion  of  proteins 
which  occurs.  The  rapidity  of  gastric  digestion 
does  not  depend  only  on  the  amount  of  gastric 


DIGESTION  IN  THE  STOMACH         387 

juice  or  pepsin  contained  in  it,  but  also  upon 
the  motor  activity  of  the  stomach  by  which  the 
gastric  juice  is  mixed  up  with  the  gastric 
contents.  Pleasurable  ideas  connected  with 
food  increase  the  gastric  juice  even  when  no 
food  reaches  the  stomach  itself,  while  unpleasant 
emotions  have  an  opposite  effect.2  Meat 
extracts,  albumoses,  and  peptones,  as  well 
as  bread,  have  a  stimulating  action,3  so  that  the 
practice  of  beginning  a  meal  with  a  small 
quantity  of  soup  is  physiologically  correct,  only 
the  soup  must  not  be  too  strong  and  it  must 
not  be  in  too  large  quantity. 

According  to  some  physiologists  alkalies 
lessen  the  secretion  of  gastric  juice,  while  acids 
stimulate  it ; 4  but  this  is  hardly  in  agreement 
with  clinical  experience,  because  small  quantities 
of  alkali,  such  as  10  grs.  of  bicarbonate  of 
soda,  given  shortly  before  a  meal  are  usually 
more  efficient  than  similar  quantities  of  mineral 
acids  in  lessening  dyspepsia;  this  is  probably 
due  to  the  slight  irritant  action  of  the  alkalies 
on  the  stomach  wall,  resulting  in  improved  cir- 
culation, and  lessened  pain  and  distension.  In 
the  case  of  carbonates  and  bicarbonates,  carbonic 
acid  is  liberated,  which  will  aid  the  carminative 
action  and  tend  to  increase  the  movements  of  the 
stomach.  Alkalies  may  also  help  by  rendering 
the  mucus  less  tenacious,  thus  allowing  the  gas- 
tric juice  freer  access  to  the  food.  Nevertheless, 
small  quantities  of  hydrochloric  acid,  such  as  10  to 
1 5  minims  of  dilute  nitro-hydrochloric  acid  (B.P.), 
given  after  a  meal,  along  with  some  preparation 
of  pepsin,  often  help  weak  digestions  very  con- 


388      TREATMENT  IN  HEART  DISEASE 

siderably.  A  good  many  years  ago  I  made  a 
study  of  the  comparative  strengths  of  many 
kinds  of  commercial  pepsins,  and  to  my 
astonishment  I  found  that  some  specimens 
which  gave  very  good  results  clinically  con- 
tained very  little  pepsin  but  a  good  deal  of 
rennin. 

The  peristaltic  movements  of  the  stomach  are 
stimulated  by  bitter  infusions5  and  by  carbonic 
acid,6  so  that  the  practice  of  giving  bitters  in 
dyspepsia  is  well  founded.  The  pylorus  is  very 
sensitive  to  the  reaction  of  gastric  juice,  thus 
a  slight  acidity  on  the  stomach  side  of  the 
pyloric  ring  forms  the  stimulus  which  relaxes 
the  tone  of  the  pylorus  and  allows  the  stomach 
contents  to  pass  into  the  duodenum.  Acidity 
on  the  duodenal  side  of  the  pylorus  produces 
closure  of  the  pyloric  valve,  so  that  the  opening 
and  closing  of  the  pylorus  is  determined  by 
the  relative  acidity  of  the  bowel  contents  on 
its  two  sides ;  thus  it  is  obvious  that  too  great 
alkalinity  or  too  great  acidity  both  cause 
spasm  of  the  pylorus,  with  retention  of  the 
contents  of  the  stomach.7  When  retained  in 
this  way,  lactic  acid  is  apt  to  be  formed  in  larger 
quantity  by  decomposition  of  hydrocarbons, 
distension  becomes  still  greater,  and  finally 
vomiting  may  occur.  Much  acidity  of  the 
gastric  juice,  therefore,  ought  to  be  combated 
by  the  use  of  alkalies  in  fairly  large  doses.  If 
an  alkaline  solution  is  sipped,  a  little  at  a  time, 
there  is  very  little  fear  of  getting  such  a  degree 
of  alkalinity  of  the  gastric  contents  as  to  cause 
spasm  of  the  pylorus.  In  addition,  however, 


EFFECT  OF  CONGESTION  389 

to  chemical  stimulation  the  pylorus  reacts  also 
to  mechanical  stimulation,8  and  if  large  pieces 
of  food  have  been  swallowed  and  remain 
undigested  in  the  stomach  they  irritate  the 
pylorus  in  their  attempts  to  pass  into  the 
duodenum,  and  thus  cause  spasm  and  irritation. 
For  example,  cheese,  which  is  a  very  useful 
food  in  many  cases  of  cardiac  disease,  because 
it  contains  proteins  without  any  of  the  soluble 
products  of  albuminous  decomposition  such  as 
are  contained  in  meat,  is  sometimes  regarded  as 
very  indigestible.  The  reason  of  this  is  that 
cheese  is  very  unabsorbent  and  the  gastric 
juice  can  only  attack  it  at  its  edges.  If 
thoroughly  comminuted  it  is  digested  quite 
readily,  but  if  swallowed  in  lumps  it  may 
remain  in  the  stomach  for  hours  with  only  its 
corners  digested,  and  will  not  pass  through  the 
pylorus.  The  consequence  of  this  is  that 
cheese  taken  in  this  way  will  remain  until  the 
contents  of  the  stomach  become  very  acid,  and 
when  vomiting  occurs  everything  is  found  to  be 
digested  excepting  the  lumps  of  cheese.  For 
this  reason  it  is  often  said  that  "cheese  digests 
everything  but  itself."  It  is  important  that  this 
should  be  understood,  because  in  cases  of  high 
tension  where  butcher  meat  is  inadvisable, 
cheese  forms  a  useful  addition  to  the  dietary. 
Thickening  of  the  mucous  membrane  by 
congestion,  such  as  is  apt  to  occur  in  backward 
flow  of  blood  from  mitral  and  tricuspid  re- 
gurgitation,  tends  to  lessen  the  size  of  the 
pylorus,  as  shown  in  the  diagram,  Fig.  108,  and 
if  the  opening  is  already  small  the  difference 


390      TREATMENT  IN  HEART  DISEASE 

caused  in  it  by  the  congestion  will  be  pro- 
portionately great.  Catarrh  of  the  mucous 
membrane  will  have  a  similar  effect,  and 
in  addition  the  larger  amount  of  mucus  secreted 
tends  to  increase  the  acidity  of  the  gastric 
contents  as  well  as  to  favour  fermentation.  In 


Fio.  108. — Diagram  to  illustrate  the  effect  of  swelling  of  the  mucous 
membranes  in  a  large  and  small  orifice.  A  and  B  are  the  muscular 
coats.  A1  and  BI  the  normal,  and  A-  and  B2  the  swollen  mucous 
membranes. 

such  a  condition  preparations  of  bismuth  along 
with  alkalies  are  most  useful. 

Cases  are  by  no  means  infrequent  in  which 
gastric  catarrh  and  consequent  dyspepsia 
appear  to  depend  on  post-nasal  catarrh,  the 
mucus  from  the  nose  along  with  the  microbes 
it  contains  being  constantly  swallowed  and  so 
infecting  the  stomach.  In  such  cases,  treatment 
directed  to  the  stomach  alone  is  of  little  use, 


ZYMOGENS  AND  ENZYMES  391 

and  much  improvement  does  not  occur  until 
the  nose  receives  attention. 

External  and  Internal  Secretions. — It  has 
been  discovered  of  late  years  that  physiological 
processes  are  much  more  complicated  than  they 
were  formerly  supposed  to  be,  and  that  secret- 
ing glands  while  pouring  out  on  a  free  surface 
an  active  secretion  like  the  gastric  juice,  are 
also  sending  back  into  the  blood  other  materials, 
which  influence  other  glands  or  organs. 

The  active  principles  or  enzymes  by  which 
complex  chemical  molecules  like  those  of 
proteins  are  split  up,  are  present  in  the  glands 
or  tissues  in  inert  forms  as  zymogens9  which 
only  act  when  they  break  up  and  yield  active 
enzymes.  They  may  be  likened  to  a  pocket- 
knife,  which  is  quite  inactive  either  for  good  or 
ill  until  the  blade  is  opened.  Then  it  will  cut ; 
and  an  active  enzyme  will  split  up  molecules. 
When  the  blade  is  again  shut  down  it  becomes 
inert ;  and  apparently  there  is  some  provision 
for  active  enzymes  again  to  become  inert 
zymogens.  Pepsin  and  acid  are  not  present  in 
the  fasting  stomach,  but  pepsinogen  and  sodium 
chloride  are  present  in  the  deeper  layers  of  the 
mucous  membrane.  When  secretion  begins, 
the  sodium  chloride  splits  up  and  forms  with 
water  hydrochloric  acid,10  while  the  sodium  passes 
into  the  blood  and  increases  its  alkalinity  so  that 
urine  secreted  at  the  height  of  gastric  digestion 
is  usually  neutral  or  alkaline,  sometimes  so 
much  so  that  it  is  actually  milky  when  passed, 
from  the  precipitation  of  alkaline  phosphates  in 
the  bladder.11  When  the  acid  chyme  passes  into 


392       TREATMENT  IN  HEART  DISEASb. 

the  intestine,  the  acid  is  absorbed  and  the 
alkalinity  of  the  blood  and  urine  lessened,  but 
in  cases  of  pyloric  stenosis  the  alkalinity  of  the 
urine  may  be  more  or  less  persistent. 

The  pepsinogen  also  breaks  up  and  pepsin  is 
secreted  into  the  stomach.12     At  the  same  time 


Walls  of  stomach. 


oqen  ror  ^ 


FIG.  109 — Diagram  to  illustrate  the  chemical  changes  in  the  stomach 
daring  secretion. 

it  is  probable  that  something  which  I  have 
marked  in  the  diagram,  Fig.  109,  as  X,  is 
returned  into  the  general  circulation  and  acts 
on  other  glands.13 

We  do  not,  at  present,  know  exactly  what  X 
is  in  the  case  of  the  stomach,  but  in  the  case  of 
the  intestine,  while  intestinal  juice  is  poured  out 


HORMONES— ASSIMILATION  393 

into  the  gut,  a  body  called  "  secretin  "  is  sent  into 
the  blood,  which,  going  to  the  pancreas,  stimu- 
lates it  to  secrete.14  Such  substances,  which  pass 
from  one  gland  into  the  blood  and  activate 
the  zymogens  in  another,  are  called  hormones 
(op/moua,  to  excite).16  But  they  have  not  all  an 
exciting  action,  for  some  check  instead  of 
activating.  For  these  the  name  of  chalones 
has  been  proposed  (xaXcua,  to  relax).16 

The  name  "autocoid  substances"  has  been 
suggested  to  include  both  hormones  and 
chalones.17 

As  the  action  of  one  organ  is  thus  so  closely 
united  with  that  of  others,  it  is  very  evident 
how  necessary  it  is  to  attend  to  all  organs  as 
far  as  possible  and  not  to  confine  the  attention 
to  one  alone,  even  though  that  organ  be  such 
an  important  one  as  the  heart. 

Intestinal  Digestion. — When  the  acid  chyme 
enters  the  intestine  from  the  stomach  it  stimu- 
lates the  mucous  membrane  to  secrete,  and 
while  the  intestinal  glands  are  pouring  a  digestive 
fluid  into  the  bowel  they  are  sending  into  the 
blood  hormones  which  stimulate  the  pancreatic 
secretion,  which,  being  poured  out  into  the 
duodenum,  finishes  the  digestion  of  proteins 
begun  in  the  stomach  and  effects  that  of  carbo- 
hydrates and  fats.18 

Absorption  and  Assimilation. — Absorption 
is  chiefly  effected  in  the  large  intestine,  and  it 
does  not  consist  in  a  mere  passage  of  soluble 
substances  from  the  intestinal  cavity  into  the 
blood-vessels  and  lymphatics  of  the  intestinal 
wall.  For  protein  substances  such  as  albumins 

2  D 


394      TREATMENT  IN  HEART  DISEASE 

which  are  in  themselves  innocuous,  are  split 
up  by  digestion  into  simpler  molecules,  the 
albumoses,  which  are  powerful  poisons  and 
rapidly  cause  death  if  injected  directly  into  the 
veins.  But  during  absorption  by  the  intestine 
synthetic  processes  appear  to  occur  by  which 
the  poisonous  albumoses  are  again  built  up 
into  innocuous  albumins  before  reaching  the 
blood.19 

Autointoxication.  —  The  process  of  dis- 
integration of  proteins  in  the  intestine  does 
not  always  stop  at  albumoses,  for  part  of  them 
is  still  further  broken  up,  either  by  the  digestive 
juices  or  by  microbes  present  in  the  intestine, 
into  amino-acids  and  toxamines — bodies  allied 
to  ammonia  in  their  chemical  nature,  and  very 
poisonous.20  Some  of  them  act  on  the  heart  and 
vessels,  and  may  not  only  raise  the  general 
blood-pressure  but  may  produce  many  symptoms 
of  cardiac  or  vascular  disorder  which  are  purely 
due  to  autointoxication  and  not  to  any  organic 
disease.21 

When  the  intestinal  contents  remain  a  long 
time  in  the  bowel  before  evacuation,  greater 
opportunity  is  afforded  for  the  production  of 
poisons  by  microbes,  and  thus  a  regular  action 
of  the  bowels  is  very  desirable. 

Action  of  the  Liver. — The  danger  of  disease 
or  death  from  autointoxication  is  greatly 
lessened  by  the  liver,  through  which  all  the 
blood  from  the  intestines  must  pass  before  it 
reaches  the  general  circulation.  The  liver 
prevents  the  organism  from  being  flooded  with 
the  large  amount  of  sugar  which  starchy  food 


A  UTOINTOXICA  TION—A  CTION  OF  U  VER  395 

yields  by  converting  it  into  glycogen  and 
storing  it  up  for  a  while,  again  pouring  it  out 
as  needed.  But  the  liver  also  seems  to  have 
the  power  of  converting  urates  into  urea,  for 
Stockvis 22  observed  that  the  pulp  of  a  liver  taken 
during  digestion  has  this  power,  though  that  of 
a  fasting  liver  has  not.  These  experiments 
were  repeated  and  confirmed  by  Brunton  and 
Bokenham23  and  by  Wiener.24  When  this 
function  is  imperfectly  performed,  urates  will 
appear  in  the  urine. 

In  addition  to  these  functions  which  are 
related  to  the  ordinary  digestion  of  food,  the 
liver  prevents  the  passage  of  poisons  from  the 
portal  into  the  systemic  circulation.  Some  of 
these  poisons  it  actually  destroys ;  ^  others  it 
catches  on  their  way  from  the  portal  vein  to 
the  vena  cava  and  secretes  them  into  the  bile, 
in  which  they  are  again  sent  back  into  the 
duodenum.26 

Here  they  may  either  be  swept  on  with 
the  intestinal  contents,  and  excreted  with  the 
faeces,  or  they  may  undergo  reabsorption  and 
pass  again  to  the  liver.  They  may  thus  go 
round  and  round  in  the  enterohepatic  circula- 
tion for  a  long  time  without  producing  much 
effect  (Fig.  105),  until  they  are  either  removed  by 
a  purgative,  or  accumulate  so  much  that  the  liver 
can  no  longer  deal  with  them,  and  they,  therefore, 
enter  the  general  circulation  and  produce  toxic 
symptoms.  Bile  is  secreted  under  very  low 
pressure,  and  the  chief  agent  in  its  expulsion 
from  the  liver  is  the  pressure  to  which  that 
organ  is  subjected  by  the  diaphragm  and 


396      TREATMENT  IN  HEART  DISEASE 

abdominal  walls.27  In  simple  walking  this 
pressure  is  so  slight  that  the  liver  is  not 
squeezed  at  all,  and  the  bile  tends  to  remain  in 
the  ducts.  But  in  climbing  a  steep  ascent,  or  in 
bending  forwards  to  touch  the  toes,  when  the 
diaphragm  is  depressed  by  a  full  inspiration, 
the  liver  is  squeezed,  the  bile  evacuated  from  it, 
and  by  a  course  of  such  exercises  many  of  the 
symptoms  known  as  "biliousness"  may  be 
removed. 

When  the  patient  is  too  feeble  for  exercises 
considerable  benefit  may  be  obtained  by  proper 
massage  of  the  liver. 

Defecation. — In  cases  of  cardiac  disease  it  is 
frequently  of  the  greatest  importance  to  avoid 
straining  at  stool.  I  have  elsewhere*  pointed 
out  that  the  anus  is  in  front  of  the  axis  of 
the  pelvis,  and  the  expulsive  efforts  tend  to 
drive  the  faecal  mass  against  the  pelvic  floor 
just  under  the  coccyx.  When  this  point  is 
supported  mechanically  the  expulsion  of  a  large 
faecal  mass  is  greatly  expedited.  Usually  it  is 
better  by  diet  and  laxatives  to  keep  the  motions 
soft,  and  if  this  is  insufficient  the  bowel  should 
be  washed  out  by  an  enema  rather  than  allow 
any  strain  which  may  produce  serious  or  even 
fatal  consequences  (cf.  p.  172). 

Metabolism.  Exercise. — We  have  already 
seen  how  the  activity  of  one  gland  promotes 
that  of  another,  and  the  internal  secretions  of 
the  thyroid28  and  pituitary29  glands  affect, to  an 
enormous  extent,  the  growth  and  development 

*  Disorders  of  Assimilation  (London  :  Macmillan  & 
Co.),  1901,  p.  231. 


EXERCISE— EXCRETION  397 

of  the  body  generally.  Every  organ  during  its 
functional  activity  seems  to  produce  substances 
which  are  useful  to  other  organs,  but  which  if 
retained  in  it  are  poisonous  to  itself.30  A  free 
flow  of  blood  through  the  organ  is,  therefore, 
necessary  not  only  for  the  supply  of  fresh  food 
materials  and  of  hormones,  but  also  for  the 
removal  of  waste  products.  Claude  Bernard31 
showed  that  when  the  submaxillary  gland  is 
made  to  secrete  by  stimulation  of  the  chorda 
tympani  nerve,  the  afferent  artery  to  the  gland 
dilates  at  the  same  time ;  and  Ludwig  and 
Sadler32  showed  that  when  muscles  are  stimulated 
to  contraction  their  arteries  dilate  so  that  more 
blood  passes  through  them.  Exercise  of  the 
muscles,  therefore,  supplies  them  with  blood, 
increases  their  contractile  power,  and  maintains 
their  nutrition,  whereas  muscles  which  are  not 
exercised  at  all  become  soft  and  flabby,  and 
lose  their  power  of  contraction  to  a  great  extent. 
The  heart  is  a  muscle  and  is  subject  to  the 
same  laws  of  nutrition  as  the  other  muscles. 
While  the  feeble  heart  is  to  be  protected  from 
over  strain,  its  nutrition  is  improved  by  moder- 
ate exercise,  and  absolute  inactivity,  where  this 
is  not  required,  is  bad  for  the  patient's  heart  as 
well  as  for  his  general  condition. 

As  I  have  already  mentioned  (p.  237),  where 
the  patient  is  unable  to  take  exercise  its  place 
may  be  supplied  to  some  extent  by  systematic 
massage. 

Excretion. — The  removal  of  the  waste  pro- 
ducts formed  by  each  organ  during  its  functional 
activity  is  effected  by  the  blood  and  lymph 


398      TREATMENT  IN  HEART  DISEASE 

which  pass  from  it,  but  unless  these  are  more 
or  less  constantly  removed  from  the  blood  it 
will  gradually  become  overcharged  with  them, 
and  will  lose  its  vivifying  power.  Attention 
to  the  due  performance  of  their  functions  by 
the  excretory  organs — bowels,  liver,  kidneys, 
and  skin — is  thus  essential  to  the  welfare  of 
the  patient.  The  necessity  for  water  has  been 
already  mentioned,  but  there  are  great  dif- 
ferences between  patients  in  the  amount  of 
water  they  naturally  take,  for  while  some  are 
liable  to  feel  thirsty  and  drink  water  freely, 
others  take  so  little  that  their  motions  are 
hard,  their  bile  scanty,  their  skin  dry,  and  their 
urine  scanty  and  concentrated.  In  such  cases 
the  necessity  for  more  water  must  be  insisted 
upon,  and  a  minimum  quantity  prescribed.  The 
eliminating  organs  must  be  stimulated  as 
required  by  laxatives,  hepatic  stimulants, 
diaphoretics,  and  diuretics. 


LITERATURE. 

1  Pawlow,  The  Work  of  the  Digestive  Glands,  trans,  by 
W.  H.  Thompson,  2nd  ed.,  1910  (London  :  Griffin  & 
Co.),  pp.  52,  95  ;  see  also  Pawlow  and  Schumowa- 
Simanovskaia,  Zentralb.  f.  Physiol.,  1889,  vol.  iii.,  p. 
113;  Arch.f.Anat.  u.  Physiol.,  1895,  P-  535  Chischin, 
Inaug.  Diss.,  1894  (St  Petersburg) ;  cf.  Jahresb. 
it.  d.  Fortschr,  d.  Thier  Chemie,  1895,  Bd.  xxiv.,  p. 
347  ;  Bidder  and  Schmidt,  Die  Verdauungssafte  und 
der  Stoffwechsel,  1852  (Leipzig) ;  Richet,  Le  Sue 
gastrique  chez  I'homme  et  les  animaux,  1878  (Paris), 
p.  153- 


LITERATURE   OF  CHAPTER  XVII.      399 

2  Pawlow,  op.  tit.,  p.  103. 

3  Pawlow,    op.  tit.)   pp.    116-19;    Schiflf,  Lecons  sur  la 

Physiologic  de  la  Digestion,  1867,  tome  ii.,  p.  205  ; 
Chischin,  op.  tit.;  Edkins,  Journ.  of  Physiol.,  1906, 
vol.  xxxiv.,  p.  139. 

4  Pawlow,  op.  tit.,  pp.  232,  244. 
6  Batelli,  Dissert.,  1896  (Genf). 

6  Schierbeck,  Skand.  Arch.  f.  Physiol.,  1891,  Bd.  iii.  ; 
Meyer  and  Gottlieb,  Exper.  Pharmakologie,  1910, 

„  p.  159- 

"  Cannon,  Mechanical  Factors  of  Digestion,  191 1  (London: 
Arnold),  p.  96  et  seq.;  Moritz,  Verhandl.  d.  dtut. 
Naturforscher  und  Aerzte,  1893,  p.  25. 

8  Cannon,  Amer.  Journ.  of  Physiol.,  1898,  vol.  i.,  p.  369  ; 

Cohnheim,  Munch.  Med.  Wochenschr.,  1907,  vol.  liv., 
p.  2582. 

9  Heidenhain,  Arch.  f.  d.  ges.  Physiol.,  1875,  Bd.  x.,  p. 

581  et  seq.;  Langley,  Journ.  of  Physiol.,  1882,  vol. 
iii.,  p.  269  ;  Moore,  Recent  Advances  in  Physiol., 
edit,  by  L.  Hill,  1908  (London  :  Arnold),  pp.  108-9. 

10  Voit,  Sitzungsber.  d.  k.-bayer.  Akad.  d.  Wissensch.  zu 

Munchen.,  1869,  Bd.  ii.,  p.  483;  Cahn,  Zeitschr.  f. 
physiol.  Chem.,  1886,  Bd.  x.,  p.  522  ;  Griiber,  Beitr. 
z.  Physiol.  (C.  Ludwig,  z.  s.  Geburtstag geivid.\  1887; 
for  theories  of  origin,  vide  Schafer's  Textbook  of 
Physiol.,  1898,  vol.  i.,  pp.  360-3. 

11  Maly,  Ann.  d.  Chem.,  1874,  Bd.  clxxiii.,  p.  232;  Quincke, 

Jahresb.  ii.  d.  Fortschr.  d.  Thier  Chemie,  1874,  Bd. 
iv.,  p.  241  ;  Stein,  ibid.,  1876,  Bd.  vi.,  p.  161. 

12  Griitzner,  Arch.  f.  d.  ges.  Physiol.,  1878,  Bd.  xvi.,  p. 

105  ;  Langley,  Journ.  of  Physiol.,  1882,  vol.  iii.,  p. 
278  et  seq. 

13  Edkins,  Journ.  of  Physiol.,  1906,  vol.  xxxiv.,  p.  133  ; 

Starling,  Recent  Advances  in  Physiol.  of  Digestion, 
1906  (London  :  Constable),  p.  75. 

14  Bayliss  and   Starling,  Journ.  of  Physiol.,  1902,  vol. 

xxviii.,  p.  325. 

15  Starling,   Recent  Advances  in  Physiol.  of  Digestion, 

1906  (London  :  Constable),  p.  90  ;  Bayliss,  Nature 
of  Enzyme  Action,  1908  (London :  Longmans,  Green). 

16  W.  R.  Hardie,  vide  Schafer,  Brit.  Med.  Journ.,  1913, 

vol.  ii.,  p.  380. 


400  LITERATURE 

17  Schafer,  Physiol.  Section,  XVII.  Internal.  Congress  of 

Medicine,  London,  Brit,  Med.  Journ.,  1913,  vol.  ii., 
p.  380. 

18  Starling,  op.  cit.,  p.  88. 

19  For  fuller  information,  vide  Lauder  Brunton,  Introd. 

to  Modern  Therapeutics,  1892  (London-  Macmillan 
&  Co.),  p.  46  ;  v.  Noorden,  Metabolism  and  Practical 
Medicine,  edit,  by  I.  Walker  Hall,  1907  (London  : 
Heinemann),  vol.  i.,  pp.  15,  64. 

20  Moore,  Schafer's  Textbook  of  Physiol.,  1898,  vol.  i., 

p.  42 1  et  seq. ;  Abderhalden,  Zeitschr.  f.  physiol. 
Chemie,  1905,  vol.  xliv.,  p.  17  ;  v.  Noorden,  op.  cit., 
vol.  i.,  pp.  9,  13. 

21  Albertoni,  Centralbl.  f.  d.  med.  Wissensch.,  1880,  vol. 

xviii.,  p.  577  ;  Schmidt-Miihlheim,  Arch.  f.  Anat.  u. 
Physiol.  Phys.  Abt.,  1880,  p.  45  ;  Lauder  Brunton, 
Disorders  of  Digestion,  1888,  pp.  247,  284;  ibid., 
Introd.  to  Modern  Therapeutics,  1892,  pp.  48,  55,  57. 

22  Stockvis,  Dander's  Archiv,  1860,  p.  260. 

23  Brunton  and  Bokenham,  Archiv  d.  Sciences  Biolog. 

de  St  Petersbourg,  tome  xi.,  Supplement,  Pawlow's 
"  Festschrift,"  1904. 

24  Wiener,  Zentralbl.f.  Physiol.,  28th  Jan.  1905,  p.  690; 

cf.  Lauder  Brunton,  ibid.,  1905,  Bd.  xix.,  No.  I. 
26  Roger,  Action  du  Foie  sur  les  Poisons,  1887  (Paris) ; 
Lauder  Brunton,  Disorders  of  Digestion,  1888,  pp.  17, 
35  ;  Rothberger  u.  Winterberg,  Arct .  intern,  de 
Phannacodyn.,  1905,  Bd.  xv.  ;  Billing,  Biochem. 
Journ.,  1909,  vol.  iv.,  p.  293. 

26  Lussana,  Lo  Sperimentale,  1872,  tome  xxix.  ;  Lauder 

Brunton,  Disorders  of  Digestion,  1888,  p.  201  ; 
Langer,  Zeitschr.  f.  exper.  Path.  u.  Ther ,  1906, 
Bd.  iii. 

27  Hermann's    Handbuch    d.    Physiol.,   1883    (Leipzig: 

Vogel),  Bd.  v.,  Theil  i.,  p.  270 ;  Noel  Paton, 
Schafer's  Textbook  of  Physiol.,  1898,  vol.  i.,  p.  567. 

28  Schafer,  Schafer's  Textbook  of  Physiol.,  1898,  vol.  i., 

P-  937  >  Pembrey,  Recent  Advances  in  Physiol.,  1908, 

P-  575- 

29  Oliver  and  Schafer,  Journ  of  Physiol.,  1895, ,  vol.  xviii., 

p.  277  ;  Dale,  Biochem.  Journ.,  1909,  vol.  iv.,  p.  427  ; 
Mackenzie,  Quart.  Journ.  of  exper.  Physiol.,  1911, 


LITERATURE  OF  CHAPTER  XVIL      401 

vol.  iv.,  p.  305  ;  Pick,  Deut.  med.  Wochenschr.,  igii, 
pp.  1930,  1978,  2086  ;  Wiggers,  Amer.  Journ.  Med. 
Sciences,  1911,  vol.  cxli.,  p.  502  ;  Gushing,  Pituitary 
Body  and  its  Disorders,  1912  (Lippincott). 

30  For  literature,  vide  Swale  Vincent,  Internal  Secretions 

and  the  Ductless  Glands,  1912  (London  :  Arnold) ; 
BiedL,  Internal  Secretory  Organs,  trans,  by  L. 
Forster,  1912  (London :  J.  Bale,  Sons,  &  Danielsson); 
Martindale  and  Westcott,  Extra  Pharmacopeia, 
1912,  1 5th  ed.,  vol.  i.,  p.  943  et  seq. 

31  Claude  Bernard,  Journ.  de  la  Physiol.,   1858,  vol.  i., 

PP-  233>  649  ;  v.  Frey,  Lud-wigs  Arbeiten,  1876, 
Bd.  xi.,  p.  89  ;  Langley,  Journ.  of  Physiol.,  1889, 
vol.  x.,  p.  316. 

32  Ludwig  and  Sadler,  Ludwigs  Arbeiten,  ivte  Jahrg.  for 

1869  (Leipzig  :  Hirzel,  1870),  p.  77. 


CHAPTER   XVIII 

TREATMENT  OF  CHRONIC  VALVULAR   DISEASE 

Aortic  Stenosis — Aortic  Regurgitation — Mitral  Stenosis 
— Mitral  Regurgitation. 

Treatment  of  Chronic  Heart  Disease.  Aortic 
Stenosis. — When  the  aortic  orifice  is  contracted 
it  presents  more  resistance  to  the  action  of  the 
ventricle,  which  therefore  undergoes  compensa- 
tory hypertrophy.  When  this  is  complete  the 
condition  may  cause  no  symptoms,  and  the  only 
treatment  required  is  to  prevent  overstrain  or 
over-excitement  of  the  heart  by  severe  physical 
exertion,  worry  or  stimulants,  and  to  prevent 
toxaemia  of  any  kind,  either  from  over-eating, 
constipation,  or  microbic  invasion.  When  com- 
pensation is  perfect  the  patient  may  present  no 
abnormal  symptoms  for  a  long  time,  and  the 
condition  is  only  recognised  by  a  systolic  bruit 
over  the  aorta.  But  whenever  the  heart  begins 
to  fail,  the  nervous  system  begins  to  show 
symptoms  of  imperfect  blood  supply,  in  the 
form  of  giddiness,  faintness  on  rising,  flashes 
of  light  before  the  eyes,  and  headache.  Very 
often  these  are  the  first  indications  of  anything 
wrong.  Then  oppression  over  the  chest  and 
cardiac  pain  may  appear.  This  pain  may  be 

402 


AORTIC  DISEASE  403 

only  a  dull  ache  coming  on  with  exertion  or 
excitement,  or  it  may  become  intense  in  the 
form  of  angina  pectoris. 

As  these  symptoms  indicate  that  the  heart  is 
no  longer  able  to  meet  the  calls  upon  it,  it  is 
necessary  to  lessen  the  work  that  it  has  got  to 
do  by  lowering  the  tension  as  a  whole,  and 
preventing  any  undue  rise  at  any  time  from 
bodily  exercise  or  mental  emotion.  The  tension 
must  be  lowered  generally  by  prohibiting  the 
use  of  red  meat  and  meat  extracts,  by  free 
elimination  from  the  liver,  kidneys  and  bowels, 
by  the  administration  of  vaso-dilators,  and  the 
use  of  Nauheim  baths  and  by  lessening  any 
irritability  present  by  nervous  sedatives.  So 
long  as  the  mitral  valves  remain  competent 
there  may  be  very  little  or  no  shortness  of 
breath,  but  as  soon  as  the  ventricle  begins  to 
yield  and  the  valves  become  incompetent 
(Fig.  24,  p.  75),  then  signs  of  pulmonary  con- 
gestion and  venous  stasis  appear. 

Aortic  Regurgitation. — In  this  condition  also 
there  may  be  few  or  no  symptoms  so  long  as 
compensation  is  perfect,  and  it  may  only  be 
recognised  by  a  diastolic  bruit.  And  here  I 
think  I  ought  to  give  a  word  of  caution  as  to 
the  place  where  the  aortic  regurgitant  murmur 
is  heard.  It  is  usually  heard  quite  markedly 
over  the  aortic  valves,  or  perhaps  I  ought  to  say 
rather  over  the  aortic  cartilage,  and  is  propagated 
down  the  sternum,  but  sometimes  it  is  not  heard 
at  all  at  the  base  of  the  heart,  and  is  only  audible 
at  the  lower  end  of  the  sternum,  more  especially 
to  its  left  side.  Not  infrequently  the  presence 


404          CHRONIC  VALVULAR  DISEASE 

of  aortic  regurgitation  is  apparent  even  to  on- 
lookers by  the  curious  pallor  of  the  face,  and  by 
visible  locomotion  in  the  temporal  and  carotid 
arteries. 

Persons  suffering  from  aortic  regurgitation 
are  more  liable  to  sudden  death  than  those 
suffering  from  any  other  form  of  cardiac  disease, 
except,  perhaps,  those  who  have  angina  pectoris. 
It  is  therefore  advisable  for  the  patient  always 
to  carry  about  with  him  a  calling  card  or  pocket- 
book  stamped  with  his  address,  so  as  to  insure 
his  identification  in  case  of  death  away  from 
home.  So  long  as  the  valvular  lesion  is  fully 
compensated,  it  is  not  advisable  to  lay  the 
patients  up.  All  that  is  necessary  is  to  warn 
them  against  sudden  strain,  undue  fatigue,  or 
great  excitement.  Many  of  them  might  walk  25 
miles  in  a  day  without  harm,  or  even  with 
positive  advantage,  but  20  yards  sudden  spurt  to 
catch  a  train  might  prove  fatal. 

The  most  important  point  in  treatment  is  to 
keep  the  heart  in  good  condition. 

For  this  purpose  courses  of  Nauheim  baths 
and  graduated  resistance  exercises  are  some- 
times very  beneficial.1  In  this  form  of  heart 
disease  the  difference  between  systolic  and  dia- 
stolic  pressure  is  greater  than  in  any  other.  In 
the  diastole  the  blood  flows  back  into  the  heart 
as  well  as  onwards  into  the  vessels.  There  is 
thus  a  tendency  for  the  diastolic  pressure  to 
sink  low,  and  if  it  should  sink  too  low  it  might 
give  rise  to  syncope,  possibly  fatal. 

The  longer  the  diastole  lasts  the  lower  does 
the  pressure  fall,  and,  therefore,  if  the  pulse  has 


SYNCOPE  IN  AORTIC  DISEASE 


405 


been  rendered  slow  by  digitalis,  greater  care 
than  usual  must  be  taken  to  avoid  bringing  on 
syncope  by  suddenly  rising  from  the  recumbent 
to  the  upright  position,  in  which  the  blood  tends 
to  flow  quickly  back  into  the  heart  and  leave 
the  brain  anaemic  (Fig.  no). 

A  special  danger  occurs  under  these  circum- 


Fio.  110.— Diagram  to  illustrate  the  occurrence  of  syncope  in  cases  of 
aortic  regurgitation.  In  a  the  normal  heart  with  full  carotid  and  free 
supply  of  blood  to  the  hrain  is  represented ;  in  6  the  carotid  is  shown 
empty,  so  that  syncope  will  occur  from  blood  flowing  back  into  the 
ventricle  as  well  as  onward  into  the  aorta ;  in  c  is  shown  aortic 
regurgitation  in  the  recumbent  posture,  so  that  the  carotid  is  well 
filled  and  regurgitation  into  the  heart  is  rather  less. 

stances  if  the  patient  suddenly  rises  to  pass 
water,  because  as  the  bladder  is  emptied  the 
pressure  on  the  abdominal  vessels  is  lessened, 
and  thus  the  blood-pressure  tends  to  fall. 

To  prevent  the  diastolic  pressure  falling  too 
much  the  arterioles  or  capillaries  tend  to  con- 
tract, but  this  contraction  may  give  rise  also  to 
very  high  tension  during  the  systole,  because  the 


406         CHRONIC  VALVULAR  DISEASE 

ventricle  contains  a  large  quantity  of  blood  which 
has  come  to  it  partly  from  the  auricles  and 
partly  has  regurgitated  from  the  aorta,  and  it 
has  to  drive  this  onward  against  the  resistance 
opposed  by  contracted  vessels.  The  ventricle 
tends  to  yield  before  the  strain  and  thus  dilata- 
tion occurs.  The  two  indications  for  treatment, 
therefore,  are,  firstly,  to  prevent  dilatation  by 
increasing  the  cardiac  nutrition  ;  and,  secondly, 
to  prevent  too  great  systolic  strain  by  dilating 
the  capillaries.  Some  interesting  results  were  ob- 
tained experimentally  by  Cloetta,2  who  produced 
aortic  regurgitation  experimentally  in  rabbits.  To 
some  of  these  he  gave  no  medicine,  and  in  them 
the  heart  became  greatly  hypertrophied,  but 
they  lost  strength  and  endurance.  When  treated 
with  digitalis  immediately  after  the  lesion,  and 
for  a  year  afterwards,  the  hypertrophy  was  much 
less,  but  the  heart  was  almost  as  strong  as  that 
of  a  normal  rabbit.  These  experiments  seem 
to  show  that  small  doses  of  digitalis,  such  as  5 
minims  of  the  tincture  three  times  a  day,  if  given 
continuously  as  soon  as  the  lesion  is  detected, 
kept  up  for  some  months,  and  again  resumed 
when  the  slightest  tendency  to  dilatation  appears, 
may  be  very  useful  by  preventing  the  ventricle 
from  yielding,  and  thus  maintaining  the  patient's 
health.  Digitalis  may  be  combined  with  strych- 
nine or  caffeine,  and  if  it  tends  to  raise  the  tension 
much  a  vaso-dilator,  such  as  nitrite  of  soda,  may 
be  given  with  it.  If  given  by  itself  in  such  doses 
as  to  raise  the  tension,  digitalis  may  evidently 
be  harmful  by  increasing  the  strain  upon  the 
ventricle,  and,  if  it  should  cause  much  slowness 


MITRAL  STENOSIS  407 

of  the  pulse,  the  tension  during  the  prolonged 
diastole  may  fall  so  far  as  to  produce  fatal  syn- 
cope. Instead  of  digitalis,  strophanthus  may  be 
employed.  Giddiness,  palpitation,  cardiac  pain, 
or  angina  must  be  treated  as  they  occur. 

Although  sudden  death  occurs  not  infrequently 
in  aortic  regurgitation,  yet  perhaps  a  still  more 
frequent  course  of  the  disease  is  for  the  left 
ventricle  to  yield  before  the  strain,  and  then  the 
mitral  valves  become  incompetent,  so  that  we 
get  all  the  consequences  which  I  have  previously 
described  from  backward  pressure  on  the  lungs 
and  right  heart.  When  this  occurs  it  must  be 
treated  like  a  case  of  severe  mitrafdisease. 

Mitral  Stenosis. — If  this  is  present  only  to  a 
very  slight  extent  it  may  not  interfere  with  the 
action  of  the  heart,  even  although  there  be  a 
pre-systolic  murmur  characteristic  of  its  presence, 
but  if  the  obstruction  be  great  it  produces  much 
congestion  of  the  pulmonary  circulation  with 
breathlessness,  cough,  and  frequently  haemop- 
tysis. In  very  many  cases  the  valves  not  only 
obstruct  the  onward  flow  of  the  blood  but  also 
tend  to  allow  free  regurgitation.  Mitral  obstruc- 
tion is  much  more  difficult  to  treat  than  mitral 
regurgitation  because  in  regurgitation  benefit 
can  be  obtained  by  strengthening  the  heart,  and 
thus  not  only  increasing  the  onward  flow  but 
lessening  the  backward  flow  by  contracting  the 
mitral  orifice  (Fig.  24,  p.  75).  In  mitral  obstruc- 
tion the  interference  with  the  circulation  cannot 
be  removed  by  drugs,  although  it  may  be  some- 
what ameliorated.  Some  patients  are  absolutely 
condemned  to  inaction,  and  so  trying  is  the  con- 


408         CHRONIC  VALVULAR  DISEASE 

dition.that  a  good  many  years  ago  I  suggested3 
that  it  might  be  possible  to  divide  the  contracted 
valves,  and  thus  convert  the  constriction  into 
pure  regurgitation.  I  had  begun  to  make 
experiments  on  the  subject,  but  a  very  severe 
illness,  lasting  more  or  less  two  years,  prevented 
me  from  continuing  them. 

Mitral  Regurgitation. — The  treatment  of 
mitral  regurgitation  depends  very  much  upon 
the  extent  of  the  lesion.  It  is  much  more 
frequent  than  it  is  usually  thought  to  be,  and 
a  great  number  of  people  go  about  with  a  slight 
mitral  leakage  which  is  never  suspected  until 
by  chance  they  are  found,  on  medical  examina- 
tion, to  have  a  murmur  indicating  mitral 
regurgitation.  They  have  no  symptoms,  they 
feel  quite  well  and  are  able  to  go  through  a 
very  considerable  amount  of  fatigue.  Some 
patients  have  had  their  lives  ruined  by  being 
told  that  they  must  throw  up  their  professions 
and  give  themselves  up  to  a  life  of  invalidism, 
taking  no  exercise  lest  they  should  further 
damage  their  heart.  Sometimes  such  advice 
is  given  but  not  taken,  and  I  well  remember 
the  case  of  a  doctor  who  had  taken  his  degree 
shortly  before  the  Crimean  War.  After  medical 
examination  he  had  been  told  that  he  had  bad 
mitral  regurgitation,  that  he  had  not  two  years 
to  live,  and  that  he  must  be  careful  to  avoid 
exertion  of  any  sort.  As  his  life  was  going  to 
be  so  short  at  any  rate,  my  friend  decided  that 
it  did  not  much  matter  what  he  did,  and  he 
accordingly  volunteered  to  go  out  to  the  Crimean 
War.  He  served  through  it,  then  through  the 


MITRAL  REGURG1TATION  409 

Indian  Mutiny,  and  lived  as  a  healthy  man  till 
between  sixty  and  seventy  years  of  age.  In 
cases  of  mitral  regurgitation  it  is  not  so  much 
the  physical  signs  that  are  to  be  taken  into 
account  in  regarding  the  patient's  life,  as  the 
effect  of  the  lesion  upon  the  patient's  condition, 
and  this  may  to  some  extent  be  ascertained  by 
noting  the  effect  upon  his  pulse  and  respira- 
tion of  running  upstairs  or,  as  in  the  observations 
of  Tait  Mackenzie,4  by  imitating  the  movement 
of  quick  running  without  moving  from  the  spot. 

Patients  having  slight  mitral  regurgitation 
are  usually  told,  and  rightly  so,  not  that  they 
have  any  disease  of  their  heart,  but  that  it  is  a 
little  weak  and  they  must  avoid  straining  it. 

As  a  general  rule  this  is  all  that  is  necessary, 
but  when  shortness  of  breath  or  symptoms  of 
venous  stasis  set  in,  more  active  treatment  is 
required,  and  here  digitalis,  strophanthus,  and 
their  congeners  have  their  proper  place.  For 
such  cases  the  baths  and  exercises  known  as 
the  Nauheim  treatment  (p.  243)  are  useful.  If 
practicable,  a  course  at  Nauheim  is,  I  think, 
preferable  to  one  at  home,  not  only  because  all 
the  arrangements  of  the  place  are  suited  to  the 
treatment  of  heart  disease,  but  also  because 
patients  can  get  there  the  mental  and  bodily 
rest  which  is  so  essential  to  a  cure,  and  which  is 
often  difficult  to  get  at  home. 


2  E 


410  LITERATURE 


LITERATURE. 

1  L.  T.  Thorne,  Nauheim  Treatment  of  Diseases  of  Heart 

and  Circulation,  3rd  ed.,  1909  (London  :    Balliere, 
Tindall  &  Cox). 

2  Cloetta,  Arch.f.  erfer.  Path.  u.  Pharm.,  1908,  Bd.  lix., 

p.  209. 

3  Lauder  Brunton,  Lancet,  1902,  vol.  i.,  p.  352. 

4  Tait  Mackenzie,  Amer,  Journ.  of  Med.  Sciences^  1913, 

vol.  cxliv.,  p.  69. 


CHAPTER   XIX 

TREATMENT   OF  SYMPTOMS  AND   FUNCTIONAL 
DISEASES 

Treatment  of  Symptoms  occurring  in  Heart  Disease 
and  of  Functional  Diseases  of  the  Heart — Palpita- 
tion—  Effect  of  Hot  Baths  —  Graves's  Disease  — 
Tachycardia  from  Strain — Paroxysmal  Tachycardia 
— Bradycardia — Stokes-Adams  Disease — Faintness 
and  Fainting — Giddiness — Shock — Sleeplessness — 
Causes  and  Treatment — Hypnotics  —  Intermittent 
and  Irregular  Pulse — Cardiac  Pain — Treatment  of 
an  attack  of  Angina  Pectoris — Diet  and  Regimen  in 
Angina  —  Angina  Abdominis — Cardiac  Asthma — 
Treatment  of  Headache  —  Flushes  of  Heat  and 
Morbid  Blushing — Raynaud's  Disease—  Chilblains 
— Chronic  Urticaria — Low  Tension — High  Arterial 
Tension — Treatment  of  Senile  Conditions  of  the 
Vessels — Cerebral  Haemorrhage — Cerebral  Throm- 
bosis. 

Palpitation. — Palpitation  may  occur  in  cases  of 
organic  disease  of  the  heart,  but  it  happens  even 
more  frequently  as  a  functional  condition,  and 
in  any  case  the  first  thing  to  do  is  to  find  out 
upon  what  it  depends  and  remove  the  cause.  In 
cases  where  it  depends  upon  excessive  use  of 
tobacco,  tea,  coffee,  or  alcohol,  these  articles 
should  be  diminished  or  cut  off  entirely.  Even 
in  cases  of  organic  heart  disease,  while  it  may 

411 


412  TREATMENT  OF  SYMPTOMS 

be  impossible  to  cure  the  lesion  it  may  be 
possible  to  relieve  the  symptoms,  for  it  may 
depend  upon  causes  apart  from  the  actual  cardiac 
disease.  Sometimes  it  depends  upon  posture, 
and  patients  who  do  not  suffer  from  it  in  the 
upright  position  may  get  it  on  lying  down.  If 
they  lie  down  on  their  left  side,  the  cardiac  apex 
comes  near  to  the  chest  wall  and  may  impinge 
upon  it  (p.  I76).1  Each  time  it  strikes  the  ribs 
the  effect  upon  the  heart  is  the  same  as  if  the 
ventricle  were  struck  by  the  ribs,  and  then  the 
action  is  excited  and  may  even  become  irregular. 
When  they  lie  upon  their  right  side  the  heart 
tends  to  fall  away  from  the  chest  wall  and  rest 
upon  the  cushion  formed  by  the  right  lung,  so 
that  many  people  can  lie  upon  the  right  side 
when  they  cannot  lie  upon  the  left.  In  some 
cases  they  are  obliged  to  lie  upon  their  backs, 
and  this  often  seems  to  disturb  the  circulation 
to  such  an  extent  as  to  cause  a  nightmare. 
Often  this  is  of  such  a  kind  as  to  indicate  inter- 
ference with  the  circulation  through  the  lungs, 
because  the  dream  which  makes  the  patient 
awaken  is  that  of  being  chased  by  an  animal  or 
subjected  to  some  other  sudden  strain,  and  when 
he  does  awake  he  has  the  same  sensation  of 
oppression,  and  his  heart  is  beating  just  as  if 
he  had  been  running  away  from  a  mad  bull  or 
undergoing  some  other  violent  exertion. 

When  palpitation  depends  upon  distension  of 
the  stomach  by  flatulence  pushing  the  heart  up,2 
and  thus  bringing  its  apex  against  the  chest 
wall,  immediate  relief  is  afforded  by  carmina- 
tives which  cause  expulsion  of  flatus  (p.  225). 


PALPITATION  413 

When  palpitation  is  very  severe  it  may  some- 
times be  relieved  by  the  application  of  cold  to 
the  chest  by  means  of  an  ice-bag  or  coils  of 
india-rubber  tubing  through  which  cold  water 
is  passed.  To  avoid  chill  it  is  advisable  to 
envelop  the  ice-bag  in  flannel  before  applying 
it  to  the  chest.  I  have  seen  the  application  of 
stimulating  liniments  over  the  cardiac  region 
bring  on  palpitation,  but  gentle  pressure  by  the 
hand  over  this  region  tends  to  quiet  the  heart. 
Continued  gentle  pressure  by  the  application  of 
a  plaster  has  a  somewhat  similar  effect,  and  a 
belladonna  plaster  appears  to  have  more  or  less 
of  a  specific  action  and  to  be  better  than  simple 
adhesive  plaster  (p.  263). 

When  the  tension  is  high  it  should  be  lowered 
by  the  administration  of  nitro-glycerine  or  some 
other  vaso-dilator,  and  small  doses  of  digitalis 
or  strophanthus  given  at  the  same  time  tend  to 
steady  the  heart  and  thus  give  relief.  If  there 
is  any  mental  excitement  (cf.  Fig.  54,  p.  164) 
and  irritation,  the  bromides  of  potassium  and 
sodium  or  ammonium3  may  be  given,  usually  in 
fairly  large  doses,  such  as  20  or  30  grs.  at  a  time. 
Their  taste  is  well  covered  by  saccharin.  Thus 
6  to  10  grs.  of  each  of  the  three  bromides  just 
mentioned  may  be  given  along  with  5  or  10 
minims  of  a  i  per  cent,  solution  of  saccharin  and 
half  a  drachm  or  a  drachm  of  tincture  of  lemon 
in  half  an  ounce  mixture.  If  this  is  taken  in 
half  a  tumbler  of  soda  water  the  taste  is  not 
disagreeable. 

Palpitation  is  very  apt  to  be  associated  with 
some  disturbance  in  the  pelvic  organs,  and  any- 


414  TREATMENT  OF  SYMPTOMS 

thing  wrong  with  these  ought  to  be  attended  to, 
any  local  lesion  treated,  and  any  excitement  of 
them  carefully  avoided. 

In  such  cases  valerian  is  useful,  and  a  very 
good  prescription  is  the  following,  which  I  owe 
to  the  late  Sir  John  Russell  Reynolds : — 

#    Tinct  Valerian  ';'"       V       3j. 

Tinct.  Lavand.  Co.      .  .         "ixx. 

Spt.  Vin.  Rect.  ad.      ^        'W\     7>ij. 
Mitte  5iv. 

Sig.  Two  fluid  drachms  measured  in  a  glass  measure 
to  be  taken  in  one  fluid  ounce  of  water. 

The  object  of  measuring  the  medicine  in  this 
way  is  to  ensure  exactitude  in  the  quantity  taken. 
It  may  be  used  at  bedtime  to  prevent  palpitation 
coming  on  and  to  bring  on  sleep,  and  may 
also  be  given  at  other  times  for  palpitation,  but 
should  not  be  used  too  freely,  as  it  may  induce 
a  craving  just  like  other  forms  of  alcohol. 

In  cases  where  palpitation  is  associated  with 
anaemia  this  condition  must  be  treated  by  pre- 
parations of  iron,  either  alone  or  with  arsenic. 
When  there  is  much  debility,  strychnine  or  nux 
vomica  is  of  great  service,  and  may  be  given  as 
in  the  prescription  for  the  "pulvis  mirabilis" 
(p.  439),  shortly  before  or  after  meals.  Its  action 
is  complex,  because  it  affects  the  whole  nervous 
system,  stimulating  the  brain,  the  medulla,  and 
the  heart.  In  most  cases  it  can  be  borne  even 
in  large  doses,  but  there  are  some  where  it 
does  harm  rather  than  good,  more  especially  in 
patients  of  a  highly  nervous  temperament,  and 
where  there  is  a  tendency  to  excessive  sensibility 
of  the  sexual  organs. 


GRA  VES'S  DISEASE  415 

Effect  of  Hot  Baths. — The  effect  of  heat  is 
to  dilate  the  blood-vessels  (p.  92)  and  at  the 
same  time  to  stimulate  the  heart.  Hot  baths 
are  therefore  to  be  avoided  by  persons  liable  to 
palpitation,  as  they  may  bring  on  an  attack. 

Graves's  Disease. — In  Graves's  disease  we 
frequently  meet  with  very  considerable  palpita- 
tion, associated  with  excessive  rapidity  of  the 
heart,  and  sometimes  we  find  these  conditions 
present  without  any  protrusion  of  the  eyeballs. 
As  I  mentioned  before  (p.  165),  palpitation  may 
be  caused  by  a  too  prolonged  administration  of 
thyroid  gland.  The  best  treatment  for  Graves's 
disease  is  undoubtedly  prolonged  rest  in  bed, 
and  one  of  the  most  successful  cases  I  ever  had 
was  a  lady  who,  luckily,  became  pregnant  shortly 
after  the  onset  of  the  disease.  She  was  kept 
constantly  in  bed  for  nine  months,  and  made  a 
perfect  recovery. 

Sometimes  both  the  palpitation  and  tachy- 
cardia which  occur  in  this  disease  are  relieved 
for  a  time  by  cold  over  the  heart.  Where  rest 
in  bed  cannot  be  borne  gentle  exercise  may  be 
allowed,  especially  in  the  open  air,  but  should 
not  be  carried  to  the  extent  of  fatigue.  The 
patient  must  be  kept  free  from  exhaustion  or 
strain,  and  anything  likely  to  cause  excitement 
should  be  avoided.  The  diet  should  be  of  an 
ordinary  mixed  character,  and  tea,  coffee,  alcohol 
and  tobacco  should  be  omitted  altogether  or 
used  very  sparingly.  Common  salt,  in  drachm 
doses,  three  times  a  day,  with  plenty  of  water, 
sometimes  appears  to  be  useful,  and  I  think  I 
have  seen  distinct  benefit  from  the  administra- 


4 16  TREA  TMENT  OF  S  YMPTOMS 

tion  of  calcium  chloride  in  5  to  10  gr.  doses 
three  times  a  day.  This  may  be  given  either 
in  milk  or  with  chloroform  water  or  saccharin, 
which  disguises  the  taste.  Kocher  *  recommends 
the  free  administration  of  phosphates. 

As  such  patients  are  usually  very  emotional, 
bromides  of  potassium,  sodium,  ammonium,  or 
strontium,  either  singly  or  combined,  are  often 
beneficial,  quieting  the  nervous  irritability  and 
removing  the  restlessness  and  sleeplessness 
which  sometimes  are  present.6 

Valerian  may  also  be  used,  either  alone,  in 
the  manner  just  recommended,  or  along  with 
bromides.  Digitalis  and  its  congeners  have 
been  very  largely  tried  but  the  result  is  some- 
what disappointing.  Belladonna  in  doses  of  5 
to  10  minims  of  the  tincture  is  sometimes  useful. 
Suprarenal  gland  has  an  antagonistic  action  to 
that  of  thyroid,  and  I  have  seen  benefit  from  its 
administration.  It  may  be  given  in  the  form  of 
a  solution  of  adrenalin  chloride  in  doses  of  I  to 
30  minims  of  a  I  per  1000  solution  three  times 
a  day,  or  hemisine  tabloids,  beginning  with  the 
third  of  a  milligramme,  three  times  a  day. 

If  the  patient  is  able  to  take  exercise,  a 
moderate  amount  of  gentle  exercise  in  the  open 
air  is  advisable;  and  where  the  patient  seems 
too  weak  for  much  exercise,  massage  may  take 
its  place  to  a  considerable  extent.  If  other 
means  fail  and  the  palpitation  is  very  distress- 
ing, the  patient  may  be  put  to  bed  and  kept  there 
steadily — regular  Weir-Mitchell  treatment,6  in 
fact,  being  adopted. 

The  serum,  the  dried  blood,  and  the   dried 


TACHYCARDIA  417 

milk  of  thyroidectomised  animals  have  been 
used,  and  in  some  cases  with  good  results.  The 
anti-thyroid  serum  may  be  given  in  5  minim 
doses,  increased  to  30  thrice  daily ;  the  dried 
blood  in  5  gr.  capsules  three  times  a  day, 
and  the  dried  milk,  with  milk  sugar  to  improve 
its  keeping  qualities,  in  doses  of  5  to  10  grammes 
daily ;  in  some  cases  as  much  as  30  grammes 
have  been  given.  The  administration  of  pan- 
creatic ferment  at  the  same  time  as  anti-thyroid 
serum  has  been  recommended  on  the  theory 
that  the  pancreatic  ferment  acts  as  a  hormone 
to  the  anti-thyroid  serum  and  increases  its 
activity. 

Tachycardia  from  Strain. — Excessive  exer- 
cise appears  to  be  followed  sometimes  by  a  rapid 
action  of  the  heart,  which,  instead  of  ceasing 
after  the  exercise  is  over,  may  continue  for  days 
or  even  weeks.  In  all  probability  such  cases 
are  due  to  a  certain  amount  of  cardiac  strain, 
and  ought  to  be  treated  as  such. 

Paroxysmal  Tachycardia.  —  In  paroxysmal 
tachycardia,  the  beats  of  the  heart,  which  may 
previously  have  been  perfectly  normal,  suddenly 
become  excessively  rapid,  as  much  as  three  or 
four  times  as  quick  as  before.  It  would  almost 
seem  in  these  cases  as  if  each  cavity  of  the  heart 
were  capable  of  giving  an  independent  stimulus 
to  the  contraction  of  the  whole,  so  that  a  pulse 
of  60  might  suddenly  jump  up  to  a  pulse  of  240. 
We  do  not  know  the  pathology  of  such  cases,7 
but  they  are  not  infrequently  associated  with 
a  certain  amount  of  fatty  degeneration  in  the 
heart.  They  are  benefited  during  the  attack  by 


4 1 8  TREA  TMENT  OF  S  YMPTOMS 

cold  applications  over  the  heart,  sometimes  by 
drinking  iced  water,  so  as  to  get  the  effect  of 
cold  directly  upon  the  heart  through  the  stomach, 
and  sometimes  by  a  powerful  stimulant,  such  as 
strong  coffee.  The  attack  may  sometimes  be 


FIG.  111. — Diagrammatic  method  of  showing  the  time-relations  of  the 
pulses  and  contractions  of  different  parts  of  the  heart  to  each  other 
in  tachycardia.  JUG  is  the  pulse  in  the  jugular  vein,  A  is  the  auricular 
impulse,  V  the  ventricular  impulse,  A-V  the  time  of  auriculo- 
ventricular  conduction.  Its  greater  or  less  obliquity  shows  the 
greater  or  less  time  required  for  the  transmission  of  an  impulse  from 
the  auricle  to  the  ventricle,  a  auricular  wave,  e  carotid  wave  = 
beginning  of  ventricular  systole,  v  end  of  ventricular  systole.  The 
diagram  shows  various  types  of  tachycardia. 

The  upper  line  I.  represents  simple  non-paroxysmal  tachycardia 
showing  the  gradual  increase  and  gradual  decrease  in  rate. 

The  middle  line  II.  represents  paroxysmal  tachycardia  with 
persistent  auricular  contraction  and  ending  in  auriculo-ventricular 
heart-block. 

The  lower  line  represents  paroxysmal  tachycardia  with  auricular 
fibrillations  and  ventricular  type  of  venous  pulse.  (After  Hirschfelder.8) 

cut  short  by  the  administration  of  an  emetic, 
such  as  20  grs.  of  sulphate  of  zinc,  or  mustard 
and  water  may  be  employed.  During  the  interval, 
small  doses  of  strophanthus,  digitalis,  strychnine, 
and  eserine  may  be  useful  in  steadying  the  heart. 
If  they  are  associated  with  high  tension,  vascular 


TREATMENT  OF  TACHYCARDIA        419 

dilators  must  be  employed  ;  and  if  they  occur 
in  gouty  people,  the  diet  should  be,  to  a  great 
extent,  non-nitrogenous.  In  some  cases  the 
attack  of  tachycardia  appears  to  be  due  to  reflex 
irritation  from  the  stomach,  and  bismuth,  sodium 
bicarbonate,  pepsin,  or  other  digestive  ferments 
are  of  service  by  lessening  dyspepsia,  while 
bromides  diminish  reflex  irritability,  and  dilute 
hydrocyanic  acid  acts  as  a  local  gastric  sedative. 
The  attacks  may  sometimes  be  cut  short  by 
stimulation  of  the  vagus,  either  directly  by 
compression  or  reflexly,  e.g.  : — 

Dr  Augustus  Waller9  found  that  the  best  way 
to  compress  the  vagus  is  to  press  the  thumb 
over  the  carotid  close  to  the  angle  of  the  lower 
jaw  and  for  a  short  distance  above  and  below, 
the  fingers  being  placed  at  the  back  of  the  neck. 
This  pressure  slows  the  pulse,  weakens  it,  and 
may  render  it  irregular.  This  condition  is 
accompanied  by  uneasiness  and  sinking  over 
the  praecordial  region.  A  sensation  of  want  of 
air  is  felt,  and  the  respiration  is  slow  and  heaving. 
There  is  also  nausea  and  even  vomiting.  The 
stomach  is  more  affected  by  compression  low 
down  than  near  the  maxilla.  When  both  vagi 
are  compressed  fainting  and  unconsciousness 
may  occur.  He  tried  the  compression  of  both 
vagi  with  success  in  tachycardia,  migraine  and 
vomiting. 

The  vagus  may  be  excited  reflexly  by  deep 
inspiration,  especially  by  yawning  and  by  deep 
inspiration  followed  by  forced  expiration,  the 
arms  being  held  tightly  across  the  chest  in  order 
to  increase  the  respiratory  effort. 


420  TREATMENT  OF  SYMPTOMS 

Bradycardia. — A  slow  pulse  may  be  con- 
genital, and  such  cases  are  better  left  alone. 
When  it  is  of  occasional  occurrence  it  is  generally 
due  to  some  irritation  of  the  vagus,  which  may, 
however,  have  its  action  increased  by  a  weak 
condition  of  the  heart  itself.  The  two  indica- 
tions for  treatment  are,  first,  to  remove  any 
irritation  of  the  vagus,  and  secondly,  to 
strengthen  the  cardiac  muscle.  The  vagus  may 
be  stimulated  at  its  roots  by  increased  pressure 
in  the  brain,  as,  for  example,  in  meningitis  and 
in  very  high  tension  occurring  in  chronic 
Bright's  disease,  or  by  the  action  of  drugs  such 
as  digitalis,  and  possibly  toxines  formed  in  the 
intestine.  In  cases  where  the  tension  is  high 
it  must  be  lowered  by  appropriate  treatment, 
p.  335,  and  if  we  suspect  toxines  we  must  try 
to  lessen  their  formation  in  the  stomach  and 
intestines  and  remove  them  by  free  purgation, 
especially  by  mercurial  salines.  If  the  toxic 
substances  are  digitalis  and  tobacco  these  must 
be  discontinued,  and  coffee  and  tea  also  if  there 
is  any  reason  to  suspect  them  as  causes.  Where 
the  slow  pulse  is  due  to  reflex  inhibition  from 
the  stomach  the  gastric  mucous  membrane 
should  be  soothed  by  the  employment  of  alkalis 
and  bismuth.  At  the  same  time  bromide  of 
potassium  may  be  employed  to  lessen  nervous 
irritability.  If  the  attack  is  very  severe  the 
addition  of  small  quantities  of  opium  to  the 
bismuth  may  be  of  advantage.  Slow  pulse  from 
weakness  of  the  cardiac  muscle  is  observed  in 
convalescence  from  fevers  and  some  febrile 
disorders,  especially  diphtheria,  influenza,  and 


BRADYCARDIA  421 

chronic  myocarditis.  In  such  cases  the  treat- 
ment is  to  strengthen  the  heart  as  far  as  possible 
by  means  of  graduated  exercises  and  tonics, 
especially  nux  vomica,  strychnine,  and  iron. 

Stokes- Adams  Disease. — Where  this  disease 
is  due  to  lesion  of  the  auriculo  -  ventricular 
bundle10  treatment  is  of  little  use,  excepting 
where  the  lesion  is  of  specific  origin.  In  such 
cases  iodide  of  potassium  should  be  given  in 
fairly  large  doses,  and,  if  it  is  not  successful  when 
given  alone,  mercury  should  be  given  along  with 
it,  either  by  the  mouth  or  by  inunction.  Iodide 
of  potassium  may  be  given  up  to  60  grs. 
or  more  three  times  a  day,  vide  p.  340.  In 
some  cases  atropine  pushed  sufficiently  far  to 
paralyse  the  vagus  improves  the  circulation  in 
the  whole  body  and  in  the  heart  itself,  so  that  it 
is  not  merely  a  palliative  but  also  more  or  less 
a  curative  remedy.  Digitalis,  although  it  tends 
to  produce  heart-block,  has  nevertheless  proved 
useful  in  certain  cases,  though  whether  this  is 
due  to  stimulant  action  on  the  cardiac  muscle 
or  not  it  is  at  present  impossible  to  say.  The 
tendency  to  faint  may  sometimes  be  averted  by 
sitting  down  with  the  head  between  the  knees 
so  as  to  increase  the  cerebral  circulation,  and 
the  inhalation  of  oxygen  appears  sometimes 
to  be  useful  during  the  attack.  Ammonium 
carbonate  has  been  said  to  abort  the  attacks. 

Paintness  and  Painting. — A  condition  in 
which  the  legs  seem  unable  to  support  the 
body  and  the  patient  wishes  either  to  sit  or  lie 
down.  It  is  often  accompanied  by  chilliness 
and  cold  sweat.  In  severe  cases  the  sight  may 


422  TREATMENT  OF  SYMPTOMS 

become  dim  and  an  appearance  of  a  black  cloud 
may  shut  out  all  external  objects  from  view. 
At  the  same  time  ringing  or  buzzing  noises  in 
the  ears  may  be  felt  in  the  head  and  yet  the 
patient  may  retain  consciousness.  When  this 
condition  becomes  a  little  more  marked  con- 
sciousness disappears  and  the  patient  will  fall  to 
the  ground  unless  supported.  These  symptoms 
are  caused  by  insufficient  supply  of  blood  to 
the  brain,  due  to  either  cardiac  failure  or 
dilatation  of  the  vessels,  especially  those  of  the 
abdomen,  so  that  the  blood-pressure  becomes 
too  low  to  maintain  the  cerebral  circulation.  The 
symptoms  may  sometimes  be  averted  mechani- 
cally by  simply  bringing  the  head  down  to  a 
lower  level  so  that  the  blood  reaches  it,  either 
by  making  the  patient  sit  with  his  head  between 
his  knees  or  lying  flat  on  the  ground.  Relief 
may  be  afforded  by  raising  the  blood-pressure 
either  by  stimulating  the  heart,  contracting  the 
vessels,  or  both.  One  of  the  most  common 
remedies  is  stimulation  of  the  nasal  mucous  mem- 
brane by  carbonate  of  ammonia  (smelling  salts)  n 
or  by  strong  acetic  acid  (aromatic  vinegar). 
These  substances  acting  through  the  nasal 
branches  of  the  fifth  nerve  cause  reflex  excite- 
ment of  the  vaso-motor  system,  with  contraction 
of  the  abdominal  blood-vessels  and  consequent 
rise  of  blood -pressure.  Sponging  of  the  face 
and  ears  with  cold  water  or  with  Eau-de-Cologne 
has  a  somewhat  similar  effect.  The  heart  and 
vaso-motor  system  may  be  stimulated  reflexly 
by  means  of  aromatic  spirits  of  ammonia,  brandy, 
or  other  strong  alcohol,  or  by  hot  drinks, 


GIDDINESS  423 

especially  hot  coffee ;  sometimes  sips  of  iced 
water  or  swallowing  pieces  of  ice  may  be  useful. 
Warm  applications  to  the  hands  and  stomach, 
such  as  hot  flannels  or  hot  water  bags,  help  the 
circulation,  and  this  may  also  be  assisted  by 
vigorous  friction  over  these  parts.  Fainting 
may  come  on  in  cases  of  aortic  regurgitation, 
and  is  then  apt  to  be  fatal.  In  such  cases  the 
venous  system  sometimes,  if  not  always,  is 
greatly  engorged,  and  if  the  patient  is  seen  at 
once  it  is  possible  that  venesection  might  be 
very  useful.  Inhalation  of  oxygen  might  also 
do  good  if  the  oxygen  were  at  hand,  and 
artificial  respiration  might  be  tried. 

Giddiness. — Failure  of  the  circulation  to  a 
less  degree  than  that  which  induces  faintness 
may  cause  giddiness  even  in  young  and  healthy 
persons,  but  this  symptom  is  very  frequently 
associated  in  elderly  people  with  some  thicken- 
ing in  the  semi-circular  canals  or  in  the  vessels 
leading  to  them  (labyrinthine  vertigo).  In  such 
cases  giddiness  is  apt  to  occur  in  a  very  severe 
form  on  sudden  movement  of  the  head,  up  or 
down,  or  from  side  to  side.  In  one  well-marked 
case  which  I  had  the  opportunity  of  observing, 
the  giddiness  only  occurred  when  the  head 
was  put  backwards  and  to  the  left.  It  could  be 
moved  into  any  other  position  without  the  least 
effect,  but  as  soon  as  this  movement  was  made 
intense  giddiness  came  on.  In  this  case  the 
atheroma  which  probably  caused  the  giddiness 
extended  afterwards  to  other  arteries,  and  the 
patient  ultimately  died  of  angina  pectoris. 
Where  giddiness  is  due  to  low  blood-pressure 


424  TREATMENT  OF  SYMPTOMS 

the  same  remedies  are  useful  as  in  cases  of 
fainting.  In  cases  of  atheroma  with  high 
tension,  nitrites,  iodides,  and  bromides  are  all 
useful,  out  the  liver  and  bowels  should  be  kept 
freely  acting  so  as  to  prevent  the  accumulation 
of  any  toxines.  It  is  sometimes  advisable  to 
warn  elderly  patients  who  suffer  from  this 
symptom  to  avoid  crossing  crowded  streets  alone, 
as  a  sudden  turn  of  the  head  to  watch  an 
approaching  vehicle  might  cause  such  giddiness 
as  to  make  them  fall  down  in  front  of  it  and 
meet  with  serious  or  fatal  injury. 

Shock. — Operations  which  will  produce  shock 
when  anaesthesia  is  imperfect  may  be  performed 
without  any  bad  result  if  the  anaesthesia  is 
complete.12  One  great  cause  of  death  from  shock 
is  that  slight  but  painful  operations  are  per- 
formed with  imperfect  anaesthesia.  The  previous 
administration  of  atropine  so  as  to  paralyse  the 
vagus  has  been  recommended  as  a  preventive. 
When  shock  has  actually  occurred  the  same 
measures  that  have  already  been  discussed 
under  the  head  of  fainting  are  indicated,  and  at 
the  same  time  the  injection  of  adrenalin  or 
pituitrin  into  the  veins  will  have  the  effect  of 
stimulating  the  heart  and  strengthening  the 
vessels.  As  rapidity  of  action  is  very  necessary 
in  such  cases,  the  quickest  way  of  giving  the 
remedies  is  to  have  them  in  small  capsules 
containing  the  dose,  which  may  be  at  once 
injected  with  a  hypodermic  syringe. 

Sleeplessness. — Although  insomnia  may  occur 
apart  from  any  disease  of  the  heart,  it  occurs 
not  infrequently  along  with  cardiac  disease  and 


SHOCK— SLEEPLESSNESS  425 

forms  one  of  its  most  distressing  symptoms. 
The  relation  between  insomnia  and  the  cerebral 
circulation  has  already  been  discussed  (p.  200), 
but  it  is  to  be  remembered  that,  apart  from  the 
circulation,  the  brain-cells  themselves  react  with 
great  readiness  to  stimuli  reaching  them  from 
any  part  of  the  body.  Their  dendrons  are 
amoeboid  and  have  the  power  of  elongation 
and  retraction.  In  all  probability  the  varied 
functions  of  the  brain  depend  on  this  power, 
which  plays  the  same  part  as  a  telephone 
exchange.  When  the  dendrons  of  a  cell  are 
elongated  so  as  to  meet  with  those  of  other 
cells,  communication  is  established  between 
them  and  lines  of  action  or  trains  of  thought 
are  established.  On  the  other  hand,  when 
the  dendrons  are  retracted  the  nerve  cells 
become  isolated,  motor  activity  ceases  as  in 
shock,  and  mental  activity  is  in  abeyance  as 
in  sleep. 

Stimuli  which  excite  cerebral  activity  may 
come  from  the  nerves  of  special  sense  of  ordinary 
sensation,  or  from  the  viscera.  The  susceptibility 
of  the  cerebrum  to  such  stimuli  will  depend 
both  on  the  quantity  and  quality  of  the  blood 
it  receives,  and  narcotic  poisons  circulating 
through  it  will  lessen  or  even  completely  abolish 
its  excitability,  while  other  substances,  like  the 
active  principles  of  tea  or  coffee,  may  increase 
its  excitability  to  such  an  extent  that  sleep 
becomes  impossible. 

When  the  brain  is  in  an  excitable  condition, 
minute  stimuli,  which  under  ordinary  circum- 
stances would  be  unfelt,  have  so  much  effect 

2   F 


426  TREATMENT  OF  SYMPTOMS 

that  they  will  keep  a  patient  awake,  and  should 
be  carefully  looked  for  and  removed. 

Powerful  or  disagreeable  impressions  on  the 
nerves  of  special  sense  must  be  avoided — no  bright 
light  should  fall  on  the  eyes — the  room  should 
be  quiet,  and  if  there  is  much  traffic  in  a  street 
outside  the  house  its  noise  should  be  deadened 
by  laying  down  straw  or  tan.  At  the  same 
time  soft  monotonous  sounds,  such  as  reading 
aloud,  are  powerfully  soporific.  There  should 
be  no  disagreeable  smell  in  the  room,  and 
commodes  should  be  at  once  emptied  after  being 
used.  Even  flowers,  although  they  make  the 
sick-room  brighter  in  the  day,  should  be  removed 
at  night.  A  persistent  bad  taste  in  the  mouth 
may  be  best  removed,  as  a  rule,  by  washing  the 
mouth  out  with  a  lotion  of  hydrogen  peroxide. 
The  pain  of  aching  teeth  may  be  lessened  by 
washing  out  the  mouth  with  a  solution  of 
sodium  bicarbonate,  which  neutralises  those  acids 
in  the  mouth  which  irritate  exposed  nerves. 
Instead  of  this  a  mixture  of  sodium  bicarbonate 
and  laudanum  may  be  rubbed  over  the  gums 
and  between  the  teeth  and  applied  on  a  pledget 
of  cotton-wool  to  any  carious  cavity. 

Cold  feet  are  a  common  cause  of  sleeplessness, 
and  the  condition  may  be  relieved  by  wrapping 
them  in  dry  warm  flannel  and  placing  an  india- 
rubber  bag  filled  with  hot  water  and  covered 
with  flannel  close  to  them.  Such  a  bag  is  better 
than  the  stone  bottles  often  used,  as  it  can  be 
more  thoroughly  applied  to  the  feet,  abdomen, 
nape  of  neck,  or  any  other  part  of  the  body  that 
may  be  cold.  Great  care  should  be  taken, 


427 

however,  that  both  bags  and  bottles  should  be 
carefully  enveloped  in  flannel,  for  I  have  seen 
bad  burns  caused  by  the  want  of  this  precaution. 
Sometimes  instead  of  putting  the  feet  into  hot 
water  or  applying  hot  bags  to  them  it  is  better 
to  put  the  feet,  one  at  a  time,  into  cold  water, 
rub  them  with  some  rough  substance,  such  as  a 
loofah,  and  then  dry  them  with  a  warm  towel 
When  the  feet  are  put  into  hot  water  the  vessels 
of  the  skin  become  dilated  at  the  time,  the  feet 
are  red  and  warm,  but  its  effect  soon  passes  off, 
the  vessels  of  the  skin  again  contract  and  the 
feet  again  become  pale  and  cold.  The  dilata- 
tion of  vessels  caused  by  rubbing  and  cold 
water  is  more  permanent  than  that  caused  by 
putting  them  in  hot  water. 

Sometimes  instead  of  being  too  cold  the 
patient  is  prevented  from  sleeping  by  being  too 
hot.  If  the  bedroom  is  not  too  cold  to  allow  of 
its  being  done  with  safety,  the  removal  of  all 
the  bedclothes,  with  perhaps  the  exception  of 
a  single  sheet,  for  ten  minutes  or  quarter  of  an 
hour  will  allow  this  feeling  to  pass  off  and  the 
patient  to  get  to  sleep.  If  he  is  strong  enough, 
to  walk  a  short  time  round  the  room  in  his 
night-shirt  while  the  bed  is  aired  and  cooled  it 
is  even  better.  Sometimes  patients  complain  of 
the  weight  of  the  bedclothes,  and  in  such  cases 
the  substitution  of  an  eider-down  quilt  for 
blankets  may  be  a  comfort.  For  patients  who 
are  well  enough  to  take  it,  a  warm  bath  some-- 
times helps  much  to  bring  on  sleep,  and  its 
quieting  influence  is  even  more  apparent  in 
children  than  in  adults.  It  should  be  warm,  but 


428  TREATMENT  OF  SYMPTOMS 

not  hot,  because  too  high  a  temperature  tends  to 
excite  the  heart,  to  produce  palpitation  (p.  415), 
and  to  prevent  instead  of  inducing  sleep.  The 
warm  water  tends  to  dilate  the  vessels  of  the 
skin,  and  by  drawing  away  blood  into  the 
cutaneous,  to  lessen  the  amount  in  the  cerebral 
area  (p.  20).  But  its  chief  action  appears  to  be 
that  of  softening  the  skin,  removing  sweat,  and 
soothing  the  cutaneous  nerves.  Instead  of  a 
warm  bath,  sponging  over  the  body  and  limbs 
may  be  employed  either  at  the  usual  time  of 
going  to  sleep  or  during  the  night  if  the  patient 
is  very  sleepless.  Even  sponging  of  the  face, 
hands,  and  feet  with  warm  water  is  often 
sufficient.  If  the  patient  is  feverish  it  is  a  good 
plan  to  sponge  the  whole  surface  of  the  body 
with  warm  water,  which  should  not  be  com- 
pletely dried  off  but  simply  dabbed  with  a  soft 
napkin,  so  as  to  leave  the  skin  somewhat  moist, 
as  if  the  patient  had  been  perspiring  gently. 
The  patient's  night  clothes  are  not  again  put 
on,  but  the  whole  body  should  be  covered  by 
one  long  cradle  or  two  short  ones  placed  end 
to  end.  Over  this  is  thrown  a  single  sheet  or 
blanket  so  that  the  moisture  from  the  patient's 
skin  evaporates  and  cools  the  body,  the  cooling 
process  being  more  complete  because  the  warm 
water  tends  to  dilate  the  cutaneous  vessels,  and 
by  thus  bringing  the  blood  to  the  surface  aids 
the  cooling  process.  When  the  patient  is  very 
feverish  it  is  sometimes  advisable  to  leave  the 
end  of  the  cradle  open  so  as  to  allow  a  freer 
circulation  of  air  under  it.  One  fact  which 
seems  to  show,  however,  that  the  soothing 


SPONGING— ITCHING  429 

effect  of  sponging  is  chiefly  due  to  its  soothing 
effect  on  the  cutaneous  nerves  rather  than  to 
any  action  on  circulation  or  temperature  is  that 
very  gentle  massage  has  a  similar  effect.  It 
should  consist  in  exceedingly  gentle  stroking 
movements  over  the  back,  limbs,  and  heart,  and 
any  strong  rubbing  is  generally  useless  or  harmful 
except  when  the  patient  has  "  the  fidgets,"  when 
gentle  kneading  of  some  muscles,  and  especially 
of  the  calves  of  the  legs,  may  be  useful.  Stroking 
the  head  and  brushing  the  hair  with  a  soft  brush 
are  sometimes  helpful.  Children  seem  naturally 
to  massage  their  eyeballs  when  they  are  sleepy 
by  doubling  their  fists  and  rubbing  their  eye- 
balls with  their  knuckles,  and  very  gentle 
rubbing  over  the  closed  eyelids  in  a  circular 
direction  with  the  tip  of  a  finger  if  well  done  has 
a  singularly  soothing  effect.  Any  local  source 
of  irritation  should  be  soothed,  such  as  bed- 
sores, patches  of  eczema,  or  pruritus  and  piles.13 
Pruritus  ani  is  a  potent  cause  of  sleeplessness. 

If  the  rectum  is  loaded  the  itching  is  usually 
worse,  so  an  enema  of  warm  water  is  advisable 
in  such  cases,  followed  by  the  introduction  of  a 
suppository  of  hamamelis  alone  or  with  conium, 
cocaine,  or  bismuth. 

The  itching  may  sometimes  be  quickly  allayed 
by  applying  to  the  anus  a  sponge  dipped  in 
water  as  hot  as  can  be  borne.  Instead  of  plain 
water  strong  solutions  of  sodium  or  potassium 
carbonate  or  bicarbonate  may  be  used.  Other 
useful  lotions  are  solutions  of  boric  acid  4  per 
cent.,  of  phenol  2  or  3  per  cent ,  of  liquor  carbonis 
or  liquor  picis  carbonis,  I  to  5  per  cent.  If  the 


430  TREA  TMENT  OF  S  YMPTOMS 

itching  is  severe  these  lotions  may  be  made  even 
stronger,  but  if  too  strong  they  cause  pain. 
Their  efficacy  may  be  increased  bythe  addition 
of  2  per  cent  of  cocaine.  After  washing,  calomel 
dusted  on  or  calomel  ointment  is  useful.  Other 
useful  ointments  are  those  of  conium,  cocaine, 
carbolic  acid,  resinol,  boric  acid,  methyl  salicy- 
late  and  menthol,  calomel,  bismuth,  subacetate 
of  lead,  and  hamamelis. 

When  other  remedies  fail  it  may  sometimes 
be  relieved  by  painting  tincture  of  iodine  around 
the  anus,  and  the  pain  this  causes  may  be 
lessened  by  applying  a  solution  of  cocaine 
before  and  cocaine  ointment  afterwards. 

Obstinate  cases  are  sometimes  cured  by 
X-rays. 

If  flatulence  or  acidity  persist  in  spite  of 
treatment  it  may  be  advisable  to  put  the 
patient  on  a  pure  milk  diet  for  several  days. 

Milk  alone  is  apt  to  become  very  disagreeable, 
but  if  it  is  flavoured  with  a  little  tea,  coffee,  or 
cocoa,  it  can  be  taken  much  more  readily.  The 
sour  milk  recommended  by  Metchnikoff  is  very 
useful  in  lessening  flatulence  and  indigestion. 
Milk  contains  a  large  quantity  of  lime  and 
therefore  tends  to  act  as  an  astringent.  It  is 
apt  also  to  form  large  clots  in  the  stomach 
unless  it  is  previously  peptonised ;  these  clots  are 
very  indigestible ;  they  may  pass  down  the  bowel 
and  cause  very  large  and  very  hard  motions.  This 
is  especially  the  case  if  the  milk  is  taken  in  very 
large  draughts,  and  in  some  Continental  milk 
cures  the  patient  is  advised  between  every  mouth- 
ful of  milk  to  chew  carefully  a  very  small  piece  of 


DIET  IN  SLEEPLESSNESS  431 

dry  hard  biscuit.  The  constipating  effect  is 
lessened  by  peptonising,  and  if  the  milk  is 
over-peptonised  it  may  sometimes  even  cause 
diarrhoea.  The  formation  of  hard  constipated 
motions  may  be  partly  prevented  also  by  the 
administration  of  half  an  ounce  of  liquid  paraffin 
every  night  at  bedtime. 

The  stomach  and  bowels  require  careful 
attention.  Overloading  of  the  stomach  by  a 
heavy  meal,  of  the  bowels  by  constipation,  or 
distension  of  either  by  flatulence  is  apt  to 
interfere  with  sleep.  It  is  advisable  that  no 
large  meal  be  taken  within  three  or  four  hours 
of  bedtime ;  faecal  accumulations  should  be 
removed  from  the  bowels  by  enemata  or  laxa- 
tives (p.  375),  and  flatulence  by  carminatives 
(p.  360).  A  very  acid  condition  of  the  gastric 
contents  tends  to  prevent  sleep  and  should  be 
counteracted  by  alkalis  (p.  356).  While  too  full 
a  stomach  is  opposed  to  sleep,  a  very  empty 
condition  has  a  similar  action,  and  warm,  light, 
digestible  food  in  not  too  great  quantity  tends 
to  induce  sleep.  The  warmth  tends  to  dilate 
the  vessels  of  the  stomach  and  thus  deplete  the 
cerebral  area  (p.  20),  but  if  the  food  is  too  hot 
the  heat  is  transmitted  through  the  diaphragm 
to  the  heart,  quickening  its  beats  and,  by  thus 
accelerating  the  circulation,  stimulating  instead 
of  soothing  the  brain.  Peptonised  milk  or 
some  of  the  numerous  patent  foods  may  be 
given  at  bedtime,  and  some  may  also  be  kept 
in  a  "  thermos  "  flask  or  baby's  food-warmer  and 
given  at  intervals  during  the  night  if  the 
patient  is  wakeful. 


432  TREATMENT  OF  SYMPTOMS 

A  warm  poultice  over  the  abdomen  or  an 
abdominalcompress  tends  to  dilate  the  abdominal 
vessels.  The  compress  may  be  made  either 
with  hot  water  or  with  cold.  It  is  easily 
prepared  by  wringing  a  towel  out  of  hot  or  cold 
water,  folding  it  to  the  proper  size,  covering 
it  with  oiled  silk,  putting  over  this  a  sheet  of 
cotton  wool  or  Gamgee  tissue  and  fastening  it 
in  place  with  a  many  tail  bandage.  A  wet  pack 
over  the  whole  body  has  a  somewhat  similar 
action,  but  I  think  in  this  the  arms  ought  not 
to  be  included,  because  the  feeling  of  restraint 
is  very  disagreeable  and  may  lead  to  struggles 
which  will  be  very  injurious.  This,  I  believe, 
is  the  cause  why  sudden  death  has  sometimes 
occurred  from  the  application  of  the  wet  pack. 

Sometimes  the  sleeplessness  may  be  due  to 
lack  of  tone  in  the  carotids,  so  that  the  moment 
the  patient  lies  down  the  blood  pours  in  full 
stream  through  the  brain  and  sleep  becomes 
impossible.  In  some  of  those  cases  the  same 
lack  of  tone  occurs  in  other  vessels  of  the  body 
and  the  patient  is  drowsy  whenever  he  sits  up. 
For  this  condition  the  best  remedy,  probably, 
is  digitalis  in  5  or  10  minim  doses,  com- 
bined with  bromide  of  sodium,  potassium  or 
ammonium  in  20  or  30  gr.  doses.  I  have 
seen  a  case  in  which  persistent  sleeplessness 
seemed  to  be  due  to  atheroma  of  the  carotid 
arteries,  which  felt  as  hard  as  pipe  stems  under 
the  fingers.  After  a  course  of  iodide  of 
potassium  and  gentle  massage  over  the  arteries 
this  hardness  became  very  much  less  and  sleep 
was  obtained. 


HYPNOTICS  433 

Hypnotics. — Hypnotics  may  be  divided  into 
(i)  those  that  act  upon  the  circulation,  (2)  those 
that  act  upon  the  brain  cells,  and  (3)  those  that 
act  upon  both.  Amongst  those  that  act  upon  the 
circulation  I  think  digitalis  comes  first  and  fore- 
most, from  its  steadying  effect  upon  the  heart 
and  its  power  to  give  tone  to  the  vessels. 
Strychnine  also  probably  acts  in  a  similar  way. 
Some  years  ago  I  described  a  case  of  persistent 
sleeplessness  due  to  continuous  hard  mental 
work  and  where  ordinary  hypnotics  were 
inadvisable.14  A  full  dose  of  nux  vomica  at 
bedtime  brought  up  the  patient's  condition 
from  that  of  being  over-tired,  when  sleep  is 
generally  poor  or  absent  altogether,  to  that  of 
being  simply  tired,  where  sleep  is  sound  and 
refreshing.  All  the  alcohols  tend  to  dilate 
vessels,  to  lessen  blood-pressure,  and  ultimately 
to  diminish  the  activity  of  the  nervous  tissues, 
although  at  first  they  may  seem  to  have  a 
stimulant  action.  For  this  reason  half  an  ounce 
to  an  ounce  of  old  whisky  or  brandy  in  two  or 
four  ounces  of  hot  water  at  night  is  even  more 
efficient  as  an  hypnotic  than  the  warm  milk 
already  spoken  of.  But  in  place  of  adding  the 
spirit  to  water  it  may  be  added  to  the  warm  milk, 
and  this  combination  is  a  very  useful  one.  Of 
the  other  substances  belonging  to  the  alcohol 
series  the  most  useful  is  par  aldehyde,15  which  in 
doses  of  half  a  drachm  to  a  drachm  often 
induces  refreshing  sleep  and  is  probably  more 
free  from  any  danger  than  almost  any  other 
hypnotic.  It  is  best  given  with  a  little  alcohol 
and  water  at  night  Its  great  drawback  is  its 


434  TREA  TMENT  OF  S  YMPTOMS 

disagreeable  and  pungent  odour,  which  remains 
in  the  patient's  breath  for  very  many  hours 
after  it  has  been  taken. 

Chloral  tends  to  a  certain  extent  to  depress 
the  action  of  the  heart,  and  for  this  reason  one 
is  inclined  to  be  careful  in  giving  it  to  patients 
with  a  weak  heart.  On  the  other  hand,  in 
patients  with  high  tension  and  a  powerful  heart 
this  effect  of  chloral  upon  the  circulation  aids 
its  action  as  a  hypnotic. 

Although  Oscar  Liebrefch16  renounced  the 
idea  which  led  him  to  use  chloral  as  a  hypnotic, 
viz.,  that  in  the  alkaline  blood  it  would  break  up 
and  yield  chloroform  which  would  then  act  on 
the  nervous  system,  yet  he  still  remained  con- 
vinced that  if  chloral  is  used  for  any  length  of 
time  the  patient  ought  to  have  an  alkaline 
course  also. 

The  fatal  effect  of  an  overdose  of  chloral, 
such  as  may  sometimes  occur  from  an  idio- 
syncrasy on  the  part  of  a  patient,  is  to  a  great 
extent  due  to  dilatation  of  the  peripheral  vessels 
and  consequent  loss  of  heat  from  the  body.  It 
may  sometimes  be  averted  by  the  simple 
application  of  warm  water  bags  or  heated 
flannels  to  the  body.17 

Butyl  chloral  is  of  little  use  as  a  hypnotic. 
Chloral  is  decomposed  by  alkalis  into  formic 
acid  and  chloroform  and  so  cannot  be  mixed 
with  ammonia,  but  a  compound  of  chloral  and 
ammonia,  called  chloralamid,  has  been  intro- 
duced with  the  idea  that  the  ammonia  would 
counteract  the  depressing  effect  of  the  chloral 
on  the  heart.  In  doses  of  15  to  45  grs.  (i  to  3 


GROUPS  OF  HYPNOTICS  435 

grs.)  it  is  sometimes  useful.  Like  chloral,  it  is 
decomposed  by  alkalis. 

Chloralose  is  a  compound  of  chloral  and 
glucose.  The  usual  dose  is  3  to  logrs.  Opinions 
are  divided  as  to  its  safety  and  depressing 
action  on  the  heart.18 

Many  mixtures  of  chloral  and  other  hypnotics 
have  been  introduced19  under  various  names, 
but  if  it  is  desired  to  prescribe  mixtures  it  is 
better  to  do  so  for  definite  quantities  of  each 
drug  adapted  to  each  patient  than  under  the 
name  of  a  drug  of  which  the  composition  may 
be  unknown  or  forgotten. 

Another  group  of  hypnotics,  in  which  sulphur 
instead  of  chlorine  is  combined  with  an  alkyl 
radical,  contains  sulphonal,  trional,  and  tetronal. 
The  dose  of  the  first  two  is  10  to  30,  that  of 
tetronal,  which  is  the  most  toxic,  is  10  to  20 
grains.  Sulphonal  ^  is  the  most  widely  used  of 
the  three,  but  it  is  sparingly  soluble,  and  is  best 
given  with  hot  brandy  and  water.  It  is  slowly 
excreted,  and  if  repeated  too  frequently,  cumula- 
tive symptoms  may  result. 

Another  group  of  hypnotics  consists  of  sub- 
stituted ureas.  Urethane21  (ethyl  carbamate) 
is  mild  and  safe  in  doses  of  10  to  60  grs. 
Hedonal 22  is  nearly  allied  to  urethane,  but  while 
it  is  also  safe  it  is  unpleasant  to  take  and  may 
produce  disagreeable  symptoms.  Veronal  ^  was 
a  very  favourite  hypnotic  in  doses  of  2  to 
10  grs.,  but  fatal  poisoning  has  occurred  even 
with  this  apparently  small  dose.  Medinal  is  the 
sodium  salt  of  veronal,  and  being  a  more  soluble 
salt,  is  more  rapid  in  its  action.  Adalin24  in  doses 


436  TREATMENT  OF  SYMPTOMS 

of  5  to  10  grs.  three  times  a  day  is  a  useful 
sedative;  in  doses  of  10  to  15  grs.,  followed 
by  a  hot  drink  half  an  hour  before  bedtime,  it  is 
said  to  be  a  prompt  hypnotic,  and  suitable  for 
cases  of  heart  disease. 

In  many  cases  of  heart  disease  a  very 
distressing  form  of  sleeplessness  occurs.  The 
patient  is  intensely  drowsy,  but  the  moment 
he  falls  asleep  he  has  feelings  of  intense 
distress  and  wakes  with  a  start  Various 
hypnotics  may  be  tried,  but  the  remedy  par 
excellence  in  this  condition,  however,  is  opium 
or  morphine.  The  latter  may  be  given  either 
by  the  mouth  or  subcutaneous  injection,  and 
the  former  either  by  the  mouth  or  rectum.  A 
convenient  way  is  to  draw  30-60  minims  of 
tincture  of  opium  into  a  glycerine  syringe  hold- 
ing 2  drachms,  then  draw  up  water  till  the 
syringe  is  full,  and  inject  into  the  rectum. 

The  advantage  this  method  has  over  adminis- 
tration by  the  mouth  is  that  one  can  be  quite 
sure  beforehand  that  the  rectum  is  empty  and 
that  absorption  will  take  place  quickly,  whereas 
the  stomach  may  contain  a  large  quantity  of  food 
or  fluid  with  which  the  opium  will  be  so  much 
diluted  that  it  may  have  hardly  any  effect. 
Sometimes  neither  opium  nor  morphine  seem 
to  produce  the  desired  effect,  even  when  given 
in  full  doses,  and  in  such  cases  a  few  whiffs  of 
chloroform  may  be  given  so  as  just  to  allow  the 
narcotic  to  take  effect 

And  here  it  may  be  well  to  say  that  I 
do  not  think  the  presence  of  albumen  in 
the  urine  contra  -  indicates  the  use  of  either 


IRREGULAR  PULSE  437 

opium  or  morphine.  The  susceptibility  of 
patients  to  these  drugs  varies  so  much  that 
it  is  impossible  to  fix  a  dose,  but  usually  one 
may  begin  with  \  or  \  of  a  grain  of  morphine 
subcutaneously,  and  increase  the  dose  carefully 
until  the  desired  result  has  been  obtained. 
Even  should  there  seem  to  be  danger  in  pushing 
the  narcotic,  it  must  be  remembered  that  to 
withhold  it  also  entails  risk,  for  the  exhaustion 
of  the  patient  by  continued  insomnia  cannot 
but  tend  towards  a  fatal  termination. 

Intermittent  and  Irregular  Pulse. — In  cases 
where  intermittence  and  irregularity  depend 
upon  mechanical  changes  outside  the  heart  from 
adherent  pericardium25  the  most  efficient  plan  of 
treatment  is  probably  to  strengthen  the  heart, 
so  as  to  enable  it  to  overcome  the  additional 
resistance  by  tonics  and  graduated  exercises. 
Although  one  would  not  recommend  it,  it  would 
appear  that  occasional  severe  exercise  has  had 
the  effect  of  restoring  the  cardiac  condition  to 
the  normal.  In  cases  of  definite  heart-block 
there  is  little  chance  of  removing  it  unless  it 
is  of  syphilitic  origin,  in  which  case  mercurials 
and  iodides  might  be  useful. 

The  same  results  as  those  from  imperfect 
heart-block  may  occur  even  from  weakening 
of  the  impulses  sent  down  by  the  auricular 
ventricular  node.  I  think  I  have  seen  this 
result  occur  temporarily  in  consequence  of 
the  administration  of  an  overdose  of  mixed 
antipyrin,  phenacetin,  and  aspirin  to  relieve 
neuralgia.  Such  weakness  is  a  cause  of 
intermittent  pulse.  The  treatment  is,  of 


4  38  TREA  TMENT  OF  S  YMPTOMS 

course,  to  strengthen  the  heart  by  strychnine, 
caffeine,  and  digitalin,  or  strophanthus,  and 
probably  camphor  might  also  be  useful.  In 
cases  where  the  heart  is  organically  diseased, 
as  in  mitral  stenosis  or  regurgitation,  these 
conditions  must  be  treated  according  to  the 
gravity  of  the  condition  (vide  p.  402).  In  the 
great  majority  of  cases,  however,  even  if  organic 
disease  be  present,  the  intermittence  or  irregu- 
larity of  the  heart  depends  upon  some  reflex 
stimulation  of  the  cardiac  nerves,  and  especially 
of  the  vagus.  It  has  already  been  mentioned, 
at  page  73,  that  this  nerve  may  be  stimulated 
reflexly  from  almost  any  organ  in  the  body, 
and  one  of  the  most  frequent  sources  of  such 
stimulation  is  dilatation  of  the  stomach  or 
intestines  by  wind  or  the  presence  in  them  of 
irritating  substances.  Very  frequently  indeed 
the  administration  of  carminatives  so  as  to  bring 
away  flatulence  will  quickly  remove  the  inter- 
mittence or  irregularity.  This  action  is  much 
assisted  by  the  simultaneous  administration  of 
bromides  to  lessen  reflex  action.  If  there  be 
much  irritation  of  the  stomach,  an  emetic  of 
plain  hot  water  or  hot  water  and  mustard  may 
give  relief  by  removing  the  irritant.  Other 
carminatives  may  be  used  (p.  360)  to  bring  the 
flatulence  away,  and  I  give  here  two  prescrip- 
tions, which  may  serve  as  examples : — 

^  Sodii  Bicarb.      .        ( '•'*•'•  gr.  v 

Spt.  ^ther  Co.  .        •,..  ;• 
Spt.  Chlorof.      A       frs.    , 
Tinct.  Cardamom.  Co.  . 
Aq.  Menth.  Pip. 

M.  mitte  sviij 


FUNCTIONAL  IRREGULARITY         439 

Sig.  One-eighth  part  to  be  taken  alone,  or  with  water, 
every  ten  or  fifteen  minutes  until  the  flatulence  is 
relieved. 


~ty  Spt.  Ammon.  Aromat.    .  .         ,,/,, 

Spt.  Chlorof.       .  .  .          ''-'.  "lx 

Tinct.  Carminativ.         .  .,  ,  nix 

Aquam    .  .  .  ad  §ss 

M.  mitte  §vj 

Sig.  One-twelfth  part  to  be  taken  alone,  or  in  water, 
every  few  minutes  until  the  flatulence  is  relieved. 

Another  useful  plan  is  to  give  about  one-third 
of  a  teaspoonful  of  sodium  bicarbonate  in  a 
claret  glassful  of  water  or  peppermint  water, 
and  to  let  the  patient  slowly  sip  as  much  of  this 
as  is  necessary.  But,  in  order  to  relieve  the 
palpitation  permanently,  the  digestion  must  be 
put  right  and  fermentation  in  the  stomach 
stopped.  We  must  remember  here  that  the 
blood  from  the  stomach  has  to  pass  through 
the  liver  before  it  reaches  the  general  circulation, 
and  that  the  liver  and  bowels  require  attention 
as  well  as  the  stomach.  We  very  frequently 
are  able  to  relieve  palpitation  far  more  by 
medicines  which  act  only  on  the  digestive  canal, 
than  by  drugs  which  affect  the  heart  and  vessels 
directly.  One  of  the  best  remedies  that  I  know 
for  functional  irritation  of  the  heart  is  one  which 
my  old  teacher,  Dr  Warburton  Begbie,  used  to 
call  the  "pulvis  mirabilis."  Its  composition 
was  as  follows  :  — 


Bismuth  Subnit. 
Sodii  Bicarb.       . 
Pulv.  Nuc.  Vom. 
Pulv.  Rhei. 
Pulv.  Cinnamom.  Co. 


gr.  x 

gr.  x 

gr.  ss-jss 

gr-  J-»J 
gr.  lij 


M.  ft.  pulv.     To  be  taken  before  each  meal. 


440  TREA  TMENT  OF  S  YMPTOMS 

The  great  disadvantage  of  this  powder  was  its 
filthy  taste,  but  this  can  be  got  over  by  putting 
the  nux  vomica  and  rhubarb  in  a  cachet,  and 
giving  the  other  ingredients  in  a  mixture,  along 
with  some  carminative  and  flavouring  substance. 
Both  the  mixture  and  cachet  are  taken  at  the 
same  time,  and,  as  they  mix  in  the  stomach, 
one  gets  the  effect  one  desires  without  the 
patient  perceiving  the  taste.  When  the  heart 
is  feeble,  3  or  4  minims  of  tincture  of 
strophanthus  or  of  digitalis  may  be  added  to 
the  mixture  with  advantage ;  and  if  the  patient 
be  anaemic,  some  preparation  of  iron  may  be 
either  given  along  with  or  separate  from  the 
medicine. 

Cardiac  Pain. — I  have  already  mentioned 
that  pain  in  the  cardiac  region  may  sometimes 
be  due  to  leucorrhcea.  Whether  this  is  caused 
by  reflex  action  or  by  general  depression  I  am 
unable  to  say,  but  it  usually  yields  readily  to  iron, 
the  preparation  which  I  have  commonly  used 
being  15  minims  of  solution  of  perchloride  of  iron 
in  an  ounce  of  infusion  of  quassia  three  times  a 
day.  I  have  seen  pain  in  the  cardiac  region 
persist  in  a  patient  for  years.  It  was  probably 
connected  in  some  way  with  cardiac  innerva- 
tion,  for  the  patient's  pressure  was  very  low  and 
the  pulsation  was  sometimes  intermittent.  It 
was  very  markedly  increased  before  or  during 
change  of  weather,  and  in  such  cases  an  anti- 
rheumatic  treatment  by  salicylates  combined 
with  tonics  is  probably  best.  I  have  also  seen 
pain  in  the  cardiac  region  lasting  for  many 
months  which  was  probably  due  to  some  form 


of  intercostal  neuralgia.  The  patient  had 
formerly  had  an  attack  of  shingles,  but  there 
were  no'vesicles  to  be  found  on  the  place  where 
this  neuralgic  pain  was  felt.  In  such  cases 
local  treatment  by  the  use  of  some  sedative 
ointment  over  the  seat  of  irritation  should  be 
tried,  and  in  a  case  associated  with  shingles  I 
have  found  blisters  and  a  cautery  over  the  roots 
of  the  second,  third,  and  fourth  dorsal  nerves  of 
the  affected  side  give  a  certain  amount  of  relief. 
Electrical  treatment  should  also  be  applied 
either  by  the  static  current  or  by  ionic 
medication. 

Treatment  of  an  Attack  of  Angina  Pec- 
toris. — The  indication  for  treatment,  of  course, 
is  to  relieve  the  heart  by  dilating  the  vessels, 
coronary26  (cf.  p.  191)  as  well  as  systemic, 
and  this  is  brought  about  most  quickly  by  the 
use  of  nitrite  of  amyl.27  Nitrobutyl  and  other 
organic  nitrites28  have  a  similar  action,  but  nitrite 
of  amyl  seems,  upon  the  whole,  to  be  the  most 
satisfactory.  Nitroglycerine  w  acts  nearly,  though 
not  quite  as  quickly,  and  is  more  convenient. 
It  has  also  the  advantage  of  dilating  the  vessels 
for  a  longer  time  than  nitrite  of  amyl.  It  may 
be  given  in  solution  with  a  little  brandy  or 
ether,  or  the  patient  may  carry  about  with  him 
nitroglycerine  tablets,  each  containing  one- 
hundredth  of  a  grain,  made  up  with  chocolate; 
and  the  best  plan,  as  a  rule,  is  not  to  swallow 
the  whole  tablet,  but  to  nibble  it  slowly  until 
the  pain  has  ceased.  If  half  a  tablet  is  sufficient, 
it  is  not  necessary  to  take  more ;  but  if  one  is 
insufficient,  then  as  many  more  may  be  taken  as 

2  G 


444 

are  necessary.  I  have  never  seen  any  bad  effect 
from  an  overdose  either  of  nitroglycerine  or 
amyl  nitrite,  except  headache,  giddinesf,  or  tran- 
sient faintness.  During  an  attack  of  angina  the 
pain  frequently  becomes  relieved  by  the  spontan- 
eous expulsion  of  wind  from  the  stomach,  and  a 
mixture  of  nitroglycerine  with  carminatives  such 
as  the  following  is  sometimes  very  useful : — 

^   Liquor  Trinit.     . 
Spt.  Ammon.  Aromat 
Spt.  Aether.  Co. 
Spt.  Chloroform 
Aq.  Menth.  Pip. 


m.x 
mx 


a 


d 


M.  mitte  jjviij 

-  lh 
relief  is  obtained 


Sig.    One  eighth  part  every  five  or  ten  minutes  till 
ief  is 


When  the  attack  is  excessively  severe  a 
neuralgic  element  may  be  superadded  to  the 
physical  condition,  and  I  think  it  is  possible 
that  sometimes  it  may  come  on  independently. 
At  any  rate,  a  subcutaneous  injection  of  a 
quarter  or  a  third  of  a  grain  of  morphine  may 
sometimes  be  necessary,  in  order  to  lessen  the 
pain  and  give  the  patient  relief,  and  a  few 
whiffs  of  chloroform  will  deaden  the  pain  until 
the  morphine  has  had  time  to  take  effect 

If  necessary,  the  morphine  must  be  pushed 
until  the  pain  is  relieved.  The  risk  from  the 
attack  is  much  greater  than  that  from  an  over- 
dose of  morphine.  A  dose  may  be  required 
which,  under  ordinary  circumstances,  might  be 
regarded  as  extremely  dangerous,  but  unless 
the  morphine  is  given  in  sufficient  quantity  it 
is  useless. 


DIET  AND  REGIMEN  IN  ANGINA       443 

Diet  and  Regimen  in  Angina. — During  the 
interval  the  tension  should  be  kept  low  by  diet, 
as  nearly  as  possible  vegetarian,  taking  care 
that  it  is  easily  digested  and  that  it  does  not 
give  rise  to  flatulence.  Tea  and  coffee,  and, 
of  course,  all  meat  extracts  which  contain 
substances  of  the  purin  type  and  tend  to  raise 
the  blood-pressure,  should  be  avoided.  The 
bowels  should  be  kept  freely  open,  and 
mercurials  should  be  given,  once,  twice,  or  three 
times  a  week  at  night,  followed  by  a  saline  in 
the  morning,  so  as  to  remove  from  the  body  all 
substances  likely  to  raise  the  blood-pressure. 
Many  substances  having  a  poisonous  action  are 
absorbed  by  the  liver  and  excreted  in  the  bile. 
They  are  reabsorbed  from  the  duodenum,  again 
passed  to  the  liver,  and  again  excreted.  This 
may  go  on  for  a  long  time  in  the  enterohepatic 
circulation,  until  they  either  accumulate  to  such 
an  extent  that  they  pass  into  the  general 
circulation  and  act  upon  the  nervous  system, 
heart,  or  other  organs,  or  are  cleared  out  by 
mercurial  purgatives  and  salines  (p.  354).  Nitro- 
erythrol,30  in  doses  of  half  a  grain  three  times 
a  day,  or  more  if  required,  will  sometimes  keep 
a  patient,  who  would  otherwise  suffer  from  angina 
pectoris,  perfectly  comfortable  for  years.  The 
hippurates  of  sodium  and  ammonium  recom- 
mended by  Oliver,86  in  doses  of  5  to  30  grs. 
three  times  a  day,  are  useful  in  some  cases  in 
lowering  the  tension.  Iodide  of  potassium,  in 
doses  of  5  to  30  grs.  three  times  a  day,  is  good 
if  the  patients  can  stand  it.  It  is  remarkable 
that  patients  who  cannot  stand  the  smaller 


444  TREA  TMENT  OF  S  YMPTOMS 

doses  can  take  10  grs.  or  more  with  comfort. 
If  iodide  of  sodium,  of  potassium,  or  of 
ammonium  cannot  be  borne,  the  organic  com- 
pounds of  iodide  such  as  iodoprotein,  iodogli- 
dine,  sajodin,  tiodine,  iothion,  or  iohydrin 
may  be  tried.  Guipsine,  a  preparation  of 
mistletoe,  has  been  found  useful  by  some 
observers  (p.  340).  The  usual  dose  is  6  to  10 
pilules,  or  one  to  two  intramuscular  injections 
daily.  Perhaps  its  failure  in  some  hands  may 
have  been  due  to  too  small  a  dose.  Electrical 
treatment  may  also  do  good  (cf.  High  Tension, 

P-  454> 

All  such  persons,  however,  should  take  care 
to  remain  quiet  for  half  an  hour  at  least  after 
every  meal,  and  when  they  get  up  they  should 
move  very  slowly  until  they  begin  to  get  warm. 
When  the  vessels  of  the  muscles  become  dilated, 
patients  are  frequently  able  to  walk  with  perfect 
comfort  even  at  a  rapid  pace.  Cf.  Influence  of 
muscular  area,  p.  18. 

Angina  Abdominis. — An  attack  of  angina 
abdominis 31  is  to  be  treated  like  one  of  angina 
pectoris,  but  during  the  intervals  not  only 
should  the  digestion  and  bowels  be  carefully 
regulated,  but  antipyrin  in  10  gr.  doses  may 
be  tried  two  or  three  times  a  day,  because  of 
its  effect  upon  the  spinal  cord,  which  is  so  well- 
known  in  the  relief  of  tabes. 

Cardiac  Asthma. — When  the  right  side  of 
the  heart  is  enfeebled  the  symptoms  of  cardiac 
asthma  are  apt  to  come  on.  The  patient  is 
quite  comfortable  so  long  as  he  remains  still, 
but  the  least  exertion  brings  on  rapid  breathing, 


CARDIAC  ASTHMA  445 

or  even  dyspnoea  and  distress.  This  condition 
is  largely  due  to  degeneration  of  the  right  side 
of  the  heart,  consequent  upon  interference  with 
the  circulation  in  the  right  coronary  artery. 
It  may  be  associated  with  fatty  degeneration 
of  both  sides  of  the  heart,  but  it  may  also  occur 
in  the  right  side  independently  of  the  left.32 
Nitrite  of  amyl  is  not  of  so  much  use  in  this  as 
in  ordinary  angina,  as  the  pulmonary  circulation 
does  not  seem  to  be  affected  by  nitrites  to  the 
same  extent  as  the  general  circulation.  Inhala- 
tion of  5  minims  of  iodide  of  ethyl  is  sometimes 
serviceable,  but  inhalation  of  oxygen  occasionally 
affords  very  great  relief,  and  in  a  case  which 
I  recently  saw  the  tension  in  the  radial  artery 
rose  under  the  influence  of  oxygen  to  an  extent 
which  I  should  not  have  believed  if  I  had  not 
seen  it  The  tension,  as  tested  by  Potain's 
instrument,  was  only  75  when  the  inhalation 
was  begun,  and  in  the  course  of  ten  minutes' 
inhalation  it  rose  steadily  until  it  had  reached 
1 50.  Hypodermic  injections  of  morphine  may  be 
required,  as  for  angina  pectoris.  The  iodide  of 
ethyl  or  nitrite  of  amyl  may  be  given  along 
with  oxygen  (Fig.  77,  p.  242). 

In  cardiac  asthma  gentle  exercises  are  useful 
as  tending  to  train  the  heart,  increase  its 
nutrition,  and  thus  accelerate  the  circulation 
through  the  lungs.  At  the  same  time,  iodide 
of  potassium,  strychnine,  digitalis,  squill,  and 
strophanthus  are  all  useful,  as  well  as  Oertel's 
treatment  (p.  250). 

On  the  Treatment  of  Headache. — Headache 
is  a  general  term  which  comprises  many  differ- 


446  TREATMENT  OF  SYMPTOMS 

ent  conditions.  The  part  of  the  head  affected 
differs  very  greatly,  so  that  commonly  one  has 
to  the  term  added  some  word  to  express  its 
position,  such  as  frontal,  temporal,  vertical,  or 
occipital.  The  kind  of  pain  also  varies  very 
greatly.  Sometimes  it  is  a  dull,  heavy,  aching 
pain,  which  seems  to  pervade  the  whole  head 
and  renders  thought  almost  impossible,  while 
at  other  times  the  pain  may  be  of  an  intense 
stabbing  or  boring  character,  excessively  severe, 
limited  to  one  part  of  the  head  or  one  temple, 
and  yet  the  brain  may  be  perfectly  clear,  and 
indeed  the  mental  faculties  may  be  even  more 
acute  than  usual.  The  pathology  of  all  these 
kinds  of  headache  have  not  been  made  out 
to  any  degree  of  certainty.  I  have  already 
described,  at  p.  184,  what  I  believe  to  be  the 
pathology  of  migraine,  and  some  other  forms 
of  headache  may  be  also  dependent  upon 
vascular  congestion  in  one  place  and  vascular 
contraction  in  another.  Whatever  be  the 
immediate  cause  of  the  pain,  it  seems  highly 
probable  that  it  is  due  in  many  cases  to  toxaemia, 
the  action  of  the  toxins  being  directed  to  the 
head  by  some  local  source  of  irritation.  When 
either  the  toxaemia  or  the  local  irritation  is 
relieved  the  pain  may  cease,  although  the  other 
factor  in  the  causation  of  the  headache  remains 
unaffected.  Amongst  the  most  common  deter- 
mining local  causes  are  eye-strain,  due  to 
inequality  of  the  focal  length  of  the  eyes, 
astigmatism,  or  weakness  of  convergence. 

The  teeth  are  a  common  cause  of  headache, 
and  irritation  in  them  may  arise  either  from 


HEADACHES  447 

decay  with  exposure  of  the  pulp  in  a  cavity, 
or  inflammation  of  the  gums,  pyorrhoea,  or 
irritation  of  the  gums  or  of  the  teeth  by  acid 
secretion  in  the  mouth.  The  nose  is  a  frequent 
cause  of  persistent  headache,  especially  of 
vertical  headache,  and  attention  must  be  paid 
to  post-nasal  catarrh  and  to  the  possibility  of 
inflammation  of  the  antra  or  sinuses.  The  ear 
should  not  be  forgotten,  especially  if  there  js 
any  discharge  or  if  there  is  deafness,  but  it  is 
less  common  than  the  other  causes.  Head- 
aches depending  upon  the  eyes  are  sometimes 
cured  by  the  use  of  proper  glasses,  those 
depending  upon  the  teeth  by  extraction  of  the 
decayed  tooth,  or  by  washing  the  mouth  with 
a  solution  of  bicarbonate  of  soda,  or  rubbing 
a  mixture  of  bicarbonate  of  soda  and  laudanum 
over  the  gums  and  applying  it  on  a  pledget  of 
cotton  wool  either  on  or  between  the  teeth. 
Irritation  in  the  nose  may  be  treated  by  nasal 
douches  and  sprays,  but  if  the  irritation  persists 
it  may  be  necessary  to  consult  a  specialist  upon 
the  subject  But  the  double  origin,  local  and 
general,  of  headaches  is  shown  by  the  fact  that 
sometimes  even  while  local  sources  of  irritation 
already  mentioned  remain  unaltered,  the  head- 
ache may  be  relieved  on  the  removal  of  toxins 
from  the  body  by  means  of  a  mercurial  pill  and 
saline  purgative.  Patients  who  suffer  from  con- 
tinuous high  tension  are  apt  to  have  attacks 
of  headache,  sometimes  extremely  severe.  The 
curious  fact  about  these  attacks  is  that  some- 
times the  patient  seems  to  have  no  recollection 
of  the  attack,  although  during  it  the  pain 


448  TREATMENT  OF  SYMPTOMS 

appeared  to  be  excruciating.  In  such  cases 
lowering  the  tension  by  mercurials,  salines, 
iodides,  nitrites,  etc,  tend  to  keep  the  headache 
away.  During  the  attack  the  feet  sometimes 
become  very  cold,  and  a  hot  foot-bath  or  hot 
applications  to  the  feet  tend  to  relieve  it.  An 
india-rubber  bag  filled  with  hot  water  placed 
under  the  nape  of  the  neck  is  sometimes  still 
more  efficacious.  Cold  lotions  to  the  forehead 
are  grateful  to  the  patient,  as  they  usually  lessen 
the  acuteness  of  the  pain.  When  the  headache 
lasts  several  days  in  succession,  blisters,  the 
size  of  a  shilling,  to  the  temples  or  nape  of  the 
neck  sometimes  give  relief.  Drugs  containing 
a  carbon  ring  -  nucleus  are  usually  more  useful 
than  others.  They  are  salicylate  of  soda, 
phenacetin,  antipyrin,  antikamnia,  aspirin, 
pyramidol,  migrainine,  etc.  What  suits  one 
patient  does  not  always  suit  another,  nor  are 
these  drugs  always  equally  efficacious  in  the 
same  patient  at  different  times.  Perhaps 
those  most  generally  useful  are  phenacetin 
and  antipyrin,  in  doses  of  8  or  10  grs.,  either 
alone  or  combined  with  about  2  grs.  of 
caffeine.  If  the  headache  is  fully  established 
little  or  no  absorption  may  occur  from  the 
stomach,  and  medicines  taken  at  these  times  will 
have  no  effect  whatever.  But  even  when  the 
headache  is  extremely  severe  and  accompanied 
by  constant  vomiting,  10  grs.  of  antipyrin 
with  2  grs.  of  caffeine  may  be  dissolved  in 
2  or  3  fluid  drachms  of  water  and  injected 
into  the  rectum.  Absorption  from  the  bowel 
does  not  seem  to  cease  at  the  same  time  as 


FLUSHES  OF  HEAT—BLUSHING        449 

absorption  from  the  stomach,  and  relief  may 
be  afforded  in  this  way.  The  pathology  of  the 
headache  which  with  many  people  comes  on 
with  the  menstrual  period,  whether  they  are 
otherwise  healthy  or  suffer  from  cardiac  disease, 
is  uncertain,  but  it  is  probably  connected  in 
great  measure  with  alterations  in  the  cranial 
circulation,  and  probably  alterations  in  the 
pressure  within  the  cranial  vessels.  One  of  the 
most  important  remedies  for  this,  of  course,  is 
rest,  and  relief  can  be  afforded  to  a  certain  extent 
by  the  other  medicines  which  I  have  already 
mentioned.  Massage  may  also  relieve. 

Where  patients  are  liable  to  awake  in  the 
morning  with  a  slight  headache,  which  gets 
worse  and  worse  during  the  day,  its  occurrence 
may  frequently  be  prevented  by  taking  at  bed- 
time on  the  previous  night  10  to  20  grs.  of 
sodium  salicylate  (natural)  with  15  to  30  grs. 
of  potassium  bromide  and  half  to  one  drachm 
of  aromatic  spirit  of  ammonia. 

Many  such  sufferers  know  when  to  expect  a 
headache,  either  because  it  usually  follows  some 
unusual  exertion,  excitement,  or  eye-strain,  or 
because  they  have  beforehand  a  warning  in  the 
shape  of  either  unusual  well-being,  depression, 
or  irritability.33 

Flushes  of  Heat  and  Morbid  Blushing. — 
Both  of  these  symptoms,  though  not  dangerous, 
are  very  annoying.  The  most  useful  remedies 
in  them  are  valerian,  sumbul,  and  the  bromides. 
Valerianate  of  zinc,  compound  asafoetida  pill, 
2  grs.  of  each,  have  been  recommended  to 
be  taken  night  and  morning.  When  they  occur 


450  TREATMENT  OF  SYMPTOMS 

at  the  menopause  15  minims  of  the  tincture  of 
perchloride  of  iron,  taken  three  times  a  day, 
is  sometimes  useful,  and  tabloids  of  ovarian 
extract  may  also  be  tried. 

RaynaucTs  Disease. — It  has  seemed  to  me 
that  this  disease  is  frequently  associated  with 
a  rheumatic  tendency,  and  I  have  used  with 
advantage  the  natural  salicylate  of  soda  and 
bromide,  10  grs.  of  the  former  and  15  of  the 
latter,  three  times  a  day  if  the  patient  is  below 
par.  Strychnine  and  arsenic  may  be  given, 
5  minims  of  the  solution  of  it  immediately  after 
meals  twice  or  three  times  a  day.  As  cold 
brings  the  attack  on,  the  part  should  be  kept  as 
warm  as  possible,  and  woollen  gloves  and  socks 
may  be  worn  at  night.  The  feet  may  be 
previously  rubbed  with  an  ointment  of  salicylate 
of  methyl.  Small  doses  of  thyroid  may  be 
given,  beginning  with  half  a  grain  every  night 
and  increasing  it  up  to  as  much  as  5  grs. 

Chilblains. — In  this  condition  I  have  also 
found  small  doses  of  thyroid  useful.  Lactate 
of  calcium,34  5  grs.,  in  the  form  of  a  tabloid, 
three  times  a  day,  has  been  recommended,  and 
in  elderly  people  a  combination  of  nitro-glycerine 
and  strophanthus.  If  the  chilblains  are  broken 
boric  acid  ointment  is  one  of  the  best  applications. 
Urticaria  sometimes  comes  on  acutely  from 
some  indiscretion  in  diet  and  in  consequence  of 
taking  shellfish,  especially  mussels.  This  may 
be  relieved  by  an  emetic  or  by  purgatives. 

Chronic  Urticaria.  —  This  is  a  most  per- 
sistent and  troublesome  ailment.  Intestinal 
antiseptics  (p.  359)  should  be  used,  and  ichthyol, 


RA  YNA  UD'S  DISEASE— LO  W  TENSION     45 1 

in  doses  of  5  grs.  in  capsule  three  times  a  day, 
has  been  specially  recommended.  Magnesia, 
either  calcined  or  the  carbonate,  in  20  gr.  doses 
three  times  a  day,  occasionally  relieves  it;  and 
if  this  is  not  sufficient  to  keep  the  bowels  freely 
open,  magnesium  sulphate  may  be  given  in 
addition.  The  itching  may  be  allayed  by  the 
remedies  already  recommended  for  this  (p.  429). 
If  any  source  of  microbic  infection  can  be 
obtained  a  vaccine  should  be  made  from  it  and 
the  patient  treated  with  it. 

Low  Tension. — One  of  the  commonest  causes 
of  this  is  over-smoking  (p.  328),  and  when  the 
tobacco  is  stopped  the  tension  gradually  rises.  As 
I  have  already  mentioned  (p.  181),  when  low  ten- 
sion is  persistent  one  must  examine  the  lungs 
carefully  for  any  trace  of  tuberculosis.  In  a  number 
of  cases  it  is  associated  with  neurasthenia,  and 
the  treatment  must  then  be  directed  to  improve 
the  digestion  so  as  to  increase  the  assimilation 
of  food,  to  strengthen  the  appetite  generally  by 
the  use  of  tonics  and  graduated  exercises,  and 
the  avoidance  of  over-work,  and  especially  of 
worry,  as  far  as  this  is  possible. 

High  Arterial  Tension. — High  arterial  tension 
in  itself  is  not  an  entirely  bad  thing  to  be  got 
rid  of  at  all  costs.  In  this  respect  it  resembles 
pain,  fever,  inflammation,  and  suppuration. 
Pain  is  nature's  warning  that  something  is  going 
wrong  and  ought  to  be  put  right ;  fever  is  one  of 
nature's  defences  by  which  microbes  which  have 
invaded  the  body  may  be  destroyed.  Inflam- 
mation, with  its  accompanying  accelerated 
circulation,  is  intended  for  the  repair  of  damaged 


452  TREATMENT  OF  SYMPTOMS 

tissues ;  while  suppuration  is  the  indication  of  a 
conflict  between  defensive  phagocytes  and 
invading  microbes.  But  pain  may  become  so 
intense  as  to  be  unbearable  and  to  render  death 
preferable  to  life.  The  temperature  in  fever 
may  rise  so  high  as  either  to  destroy  life  at 
once,  or  seriously  damage  the  vital  organs. 
Inflammation  may  go  on  to  destruction  instead 
of  repair  of  the  tissues,  and  suppuration  may 
lead  to  accumulations  of  pus  which  require 
surgical  interference  for  their  removal.  In  the 
same  way  high  tension  and  the  cardiac  hyper- 
trophy which  usually  accompanies  and  helps  to 
maintain  it,  are  a  provision  of  nature  in  order 
to  maintain  the  circulation  in  spite  of  increased 
resistance,  so  that  it  is  beneficial  to  the  organism, 
and  many  men  who  have  it  are  distinguished 
by  their  extraordinary  vitality,  energy,  and 
power  of  work  and  endurance,  both  physical 
and  mental,  the  high  tension  keeping  up  an 
abundant  supply  of  blood  to  all  the  organs. 
But,  nevertheless,  high  tension  is  a  source  of 
danger,  and  it  may  cause  death  either  through 
cardiac  failure  or,  more  commonly,  rupture  of 
a  vessel  in  the  brain. 

Treatment  of  Senile  Conditions  of  the 
Vessels. — Although  I  do  not  quite  agree  with 
him  in  every  respect,  I  think  that  my  former 
pupil  and  old  friend,  Dr  Haig,35  has  done  a  very 
great  service  by  drawing  general  attention  to 
the  injurious  effects  of  a  too  highly  nitrogenous 
diet.  In  cases  where  the  arterial  tension  tends 
to  rise  much  above  the  normal,  the  proteins  in 
food  should  be  kept  as  low  as  they  possibly 


HIGH  ARTERIAL  TENSION  453 

can,  consistently  with  the  proper  performance 
of  the  bodily  functions.  The  bowels  should 
also  be  kept  free,  either  by  the  use  of  salines  or 
by  small  quantities  of  some  aperient  such  as 
cascara,  aloes,  or  rhubarb,  along  with  each  meal, 
so  that  the  natural  stimulating  effect  of  food 
upon  the  bowels  as  well  as  the  stomach  may 
be  increased.  Nor  should  the  occasional  use  of 
a  mercurial  purgative  be  omitted ;  and  here 
I  may  mention  that  the  danger  of  mercury 
in  albuminuria  has,  I  think,  been  greatly 
exaggerated,  and  has  sometimes  in  my  own 
experience  been  productive  of  much  harm,  for 
I  have  met  practitioners  who  have  been  so 
imbued  with  the  fear  of  mercury  that  they 
would  not  give  it  in  cases  of  cardiac  disease 
either  as  a  purgative  or  in  combination  with 
digitalis,  because  albumen  had  appeared  in  the 
urine ;  whereas  in  these  very  cases  mercury 
was  one  of  the  best  things  to  restore  the  circula- 
tion to  its  normal  condition  and  cause  the 
albumen  to  disappear. 

The  steady  employment  of  iodides  is  some- 
times most  useful,  and  I  have  found  great 
advantage  in  a  number  of  cases  of  high  tension 
from  20  grs.  of  nitrate  of  potash  along  with 
|  to  2  grs.  of  nitrite  of  sodium  given  in  a 
tumbler  of  water  or  aperient  water  every  morn- 
ing on  rising.  This  seems  to  keep  the  tension 
from  rising  too  high,  and  the  treatment  may 
be  continued  with  advantage  for  years. 

Where  this  is  insufficient,  it  may  be  supple- 
mented by  2  or  3  grs.  of  sodium  nitrite  in 
water  every  four  hours,  or  by  nitro-erythrol 


454  TREATMENT  OF  SYMPTOMS 


in  doses  of  ^  to  2  grs.,  or  -^  gr.  nitro- 
glycerine in  tablets  or  solution.  Ammonium 
hippurate,  as  recommended  by  Oliver,36  may 
also  be  useful.  Electrical  treatment  by  high 
frequency  currents  as  a  rule  is  successful  in 
lowering  the  tension,  at  least  for  a  time. 

In  very  high  tension  it  may  be  advisable  to 
bleed  from  the  arm.  The  effect  of  this  in 
relieving  angina  was  most  strikingly  shown  in 
the  patient  whom  I  was  afterwards  able  to 
relieve  by  the  use  of  nitrite  of  amyl.37 

By  careful  estimation  of  the  blood-pressure, 
and  by  keeping  the  tension  at  a  proper  level 
by  diet  regimen  and  medicines,  I  believe  that 
the  cardiac  failure  or  the  cerebral  apoplexy, 
which  are  common  causes  of  death  in  advanced 
years,  may  be  averted  for  years,  and  the  life 
not  only  prolonged  greatly,  but  the  senile  decay 
or  paralysis,  which  are  so  trying  to  the  patients 
themselves  and  their  friends,  may  be  prevented.38 

Aneurism.  —  The  indications  in  aneurism  are  : 
first,  to  lessen  pressure,  so  as  to  prevent  further 
distension  ;  second,  to  keep  up  the  general 
nutrition,  so  that  the  diseased  artery  may  be 
nourished  as  well  as  the  rest  of  the  body,  and 
thus  prevent  it  from  yielding  further  ;  third,  to 
induce  cure  by  means  of  clotting  inside  the 
vessel  if  possible;  and  fourth,  to  relieve  pain. 
Avoidance  of  any  strain,  mental  or  bodily,  and 
the  measures  calculated  to  lessen  pressure  are 
to  be  adopted  (p.  335).  A  certain  amount  of 
exercise  without  strain  is,  I  think,  advantageous 
by  keeping  the  body  generally  in  a  good  con- 
dition, and  if  this  cannot  be  had,  its  place  may 


ANEURISM— CEREBRAL  HAEMORRHAGE  455 

be  taken  to  a  certain  extent  by  massage. 
Clotting  may  be  favoured  by  a  considerable 
amount  of  milk  in  the  diet  and  the  administra- 
tion of  lime  salts  such  as  calcium  chloride,39  10 
gr.  doses  or  more  three  times  a  day.  The 
most  efficacious  remedy  for  relieving  pain  is, 
I  think,  usually  iodide  of  potassium,  but  it  must 
be  given  in  large  doses.  Anything  under  20 
grs.  three  times  a  day  is,  I  think,  generally 
useless,  and  to  be  efficient  it  must  generally 
be  given  in  doses  of  30  grs.  three  times  or  more 
a  day. 

Cerebral  Haemorrhage. — When  a  vessel  has 
ruptured  in  the  brain  one  of  the  first  objects 
•in  treatment  is  to  lessen  the  blood  -  pressure, 
so  as  to  prevent,  as  far  as  possible,  further 
haemorrhage  from  taking  place.  Probably  the 
quickest  way  of  doing  this  is  by  bleeding 
from  the  arm,  an  old-fashioned  remedy  too 
much  neglected.  It  not  infrequently  happens, 
if  the  haemorrhage  is  severe,  that  the  blood 
becomes  venous  and  will  not  flow  when  the 
vein  is  opened.  If  this  is  the  case,  oxygen 
should  be  used  if  possible  (p.  147).  The  patient 
should  be  kept  perfectly  quiet,  in  the  recumbent 
position  but  turned  slightly  on  one  side,  with 
the  head  somewhat  raised,  so  as  to  lessen  the 
pressure  in  the  cerebral  vessels.  Hot  water 
bags  or  bottles  may  be  applied  to  the  feet  and 
hands,  and  mustard  leaves  to  the  calves  of  the 
legs,  so  as  to  draw  the  blood  from  the  brain  as 
far  as  possible,  but  care  must  be  taken  not  to 
burn  the  skin.  The  bowels  should  be  opened  by 
5  grs.  of  calomel  or  half  a  minim  to  a  minim  of 


456  TREATMENT  OF  SYMPTOMS 

croton  oil  mixed  with  30  minims  of  either  castor, 
almond,  or  olive  oil,  and  placed  on  the  tongue. 
Should  the  patient  gradually  recover,  the  diet 
should  be  chiefly  or  almost  entirely  milk  for 
several  days,  but  if  the  coma  should  be  of  long 
duration  nutrient  enemata  may  be  employed. 
After  recovery  the  dietetic  and  medical  treatment 
should  be  that  for  high  pressure.  If  the  patient 
after  recovering  consciousness  has  much  head- 
ache, leeches  should  be  applied  over  the  temples 
or  behind  the  ear,  or  small  blisters  about  the 
size  of  a  shilling  over  the  same  places. 

Cerebral  Thrombosis. — The  condition  here 
is  usually  exactly  the  opposite  of  that  in 
haemorrhage,  the  blood  -  pressure  being  low 
and  the  blood  poor,  so  that  clotting  occurs 
readily.  In  treating  it,  however,  complete  rest 
is  required  also,  but  instead  of  remedies 
calculated  to  lower  the  blood-pressure,  stimu- 
lants to  keep  up  the  circulation  are  necessary. 
The  best  of  these  probably  is  strychnine, 
in  doses  of  -fa  to  -fa  of  a  grain  given  hypo- 
dermically.  In  order  to  lessen  the  tendency 
to  clot,  citric  acid  or  citrate  of  potash  may 
be  given,  either  in  the  form  of  citric  acid 
itself  in  15  gr.  doses  or  the  juice  of  half  a 
lemon,  sweetened  if  required.  Theoretically,  at 
least,  milk  is  objectionable ;  it  contains  a  large 
quantity  of  calcium  salts,  and  therefore  tends 
to  increase  the  clotting  power  of  the  blood 
and  to  constipate  the  bowels.  It  is  desirable 
that  the  bowels  should  be  kept  open,  but  only 
by  gentle  purgatives,  and  not  by  such  drastic 
purgatives  as  in  cerebral  haemorrhage.  Beef 


CEREBRAL  THROMBOSIS  457 

tea  and  strong  soups  are  indicated,  while  in 
cerebral  haemorrhage  they  would  be  objection- 
able. In  cases  where  there  is  any  suspicion 
of  the  thrombosis  depending  upon  syphilitic 
endarteritis,  iodide  of  potassium  should  be 
administered,  and  if  necessary  mercurial 
inunction  may  be  employed.  Even  in  cases 
where  there  is  no  suspicion  of  a  specific 
disease  iodide  of  potassium  may  be  given  in 
the  hope  of  causing  absorption  of  the  thrombus. 


LITERATURE. 

1  Lauder     Brunton,     "  On      Digitalis,"     Prize     Thesis 

(London  :  Churchill)  ;  reprinted  in  Collected  Papers, 
First  Series  (London  :  Macmillan  &  Co.),  p.  52. 

2  Barclay,  Brit.  Med.  Journ.,  1912,  vol.  ii.,  p.  778. 

:i  Lauder  Brunton,  Practitioner,  1896,  vol.  Ivii.,  p.  48. 

4  Kocher,  Brit.  Med.Joum.,  1906,  vol.  i.,  p.  1266. 

5  Lauder  Brunton,  St  Barth.'s  Hosp.  Journ.,  1897,  vol. 

v.,  p.  33 

0  Weir-Mitchell,  Fat  and  Blood,  4th  ed.,  1885  (Phila- 
delphia) ;  Hale  White,  Text-book  of  Pharmacology 
and  Therapeutics,  1901  (London) :  Pentland,  p. 
906. 

7  For  literature,  vide  Martius,  Tachycardie,  1895  (Stutt- 
gart) ;  Hirschfelder,  Diseases  of  the  Heart  and 
Aorta,  1910,  p.  572. 

*  Hirschfelder,  op.  cit.,  1910,  p.  562. 

9  A.  Waller,  Practitioner,  1870,  vol.  iv.,  p.  193  et  seq. 

10  Gibson  and  Ritchie,  Edin.  Med.  Journ.,    1909,  New 

Series,  vol.  ii.,  pp.  315  and  507. 

11  Lauder  Brunton,  Practitioner,   1873,  vol.  xi.,  p.  246  ; 

reprinted    in    Collected    Papers,    First     Series,    p. 
407. 

12  Ibid.,  p    241  ;   ibid.,  Brit.  Med.  Journ.,   1875,  vol.  ii., 

p.  695  ;  and  1891,  vol.  ii.,  p.  1088. 

2  H 


458  LITERATURE 

13  Lauder  Brunton  and  others,  Brit.  Med.  Journ.,  1905, 

vol.  ii.,  p   1002. 

14  Lauder  Brunton,  Practitioner,  1888,  vol.  xl.,  p.  28. 

16  Cervello,   Arch.  f.  exp.   Path.  u.  Pharm.,   1883,  Bd. 

xvi.,  p.  265  ;  Bumke,  Munch.  Med.  Wochenschr., 
1902,  p.  1958. 

10  O.  Liebreich,  Das  Chloral,  ein  neues  Hypnoticum  und 
Anastheticum,  3**  Aufl.,  1871  (Berlin),  p.  26 ; 
Hermann,  Lehrbuch  d.  exp.  Toxikologie,  1874 
(Berlin),  p.  271  ;  Tomaszewicz,  Pflii get's  Arch., 
1874,  Bd.  ix.,  p.  35  ;  Archangelsky,  Arch.  f.  exp. 
Path  u.  Pharm.,  1901,  Bd.  xlvi.,  p.  347. 

17  Brunton  and  Strieker,  Journ.  of  Anat.  and  PhysioL, 

1874,  vol.  viii.,  p.  332  ;  and  Collected  Papers,  First 
Series,  p.  197. 

18  Robert  Jones,   Lancet,  1913,  vol.  ii.,  p.  712  ;  W.    H. 

Willcox,  Brit.  Med.  Journ.,  1913,  vol.  ii.,  p.  662. 

19  W.    H.   Willcox,   Brit.   Med.  Journ.,    1913,   vol.    ii., 

p.  662. 

20  Kast,  Berl.  Klin.  Wochenschr.,  1888,  p.  309  ;  Baumann 

and  Kast,  Zeitschr.  f.  physiol.  Chemie,  1890,  Bd. 
xiv.,  p.  52  ;  Kast,  Arch.  f.  exp.  Path.  u.  Pharm., 
1893,  Bd.  xxxi.,  p.  69  ;  see  also  Morro,  Deut.  Med. 
Wochenschr.,  1894,  Nos.  34  and  30 ;  Kobert, 
Lehrbuch  d.  Intoxikationen,  2te  Aufl.,  1906,  Bd.  ii., 
pp.  954-9. 

21  Schmiedeberg,    Arch.  f.  exp.  Path.  u.  Pharm.,  1886, 

Bd.  xx.,  p.  203. 

22  Dreser,  Versainml.  d.  Naturforscher  und  Aerzte.,  1899  ; 

E.  Miiller,  Munch.  Med.  Wochenschr.,  1901,  Nr.  x.,  p. 

383  (literature).     See  also  Brit.  Med.  Journ.  (Epit.), 

1905,  vol.  i.,   p.  34  ;  and  Brit.  Med.  Journ.,    1909, 

vol.  i.,  pp.  553-5. 
••'  E.  Fischer  and  v.  Mering,  Therapie  der  Gegenwart, 

1904,  vol.  xlv.,  p.  97  ;  Aug.  Hofmann,  Inaug.  Diss., 

Giessen,  1906  ;  for  recent  literature,  vide  Martindale 

and  Westcott,  Extra  Pharmacopeia,  1912,  I5th  ed., 

p.  778. 
24  Pharmaceut.  Zeitung,  1910,  p.   1029  ;  Froehlich,  Brit. 

Med.  Journ.  (Epit.),  1911,  vol.  i.,  p.  56;  Kalischer, 

ibid.,  1911,  vol.  ii.,  p.  48. 


LITERATURE  OF  CHAPTER  XIX.        459 

25  Cantlie,  Brit.  Med.  Journ.,  1889,  vol.  i.,  p.  833. 
2ti  Voegtlin    and    Macht,  Journ.   of  Pharmacology  and 
Exp.  Therapeutics,  1913,  vol.  v.,  p.  82. 

27  Lauder  Brunton,  Lancet,  1867,  vol.  ii.,  p.  97  ;  Reports 

of  the  Clinical  Society,   1870,  vol.  iii.  ;  reprinted  in 
Collected  Papers,  First  Series,  pp.  137  and  185. 

28  D.  J.  Leech,  The  Pharmacological  Action  and  Thera- 

peutical Uses  of  fhe  Nitrites  and  allied  Compounds, 

1902,  pp.  113-6. 
211  Brunton   and   Tait,  St  Earth: 's  Hosp.  Reports,  1876, 

vol.  xii.,  p.  144  ;  reprinted  in  Collected  Papers,  First 

Series,  p.  474  ;  W.  Murrell,  Lancet,  1879,  vol.  i.,  pp. 

80,  113,  151,  225  ;  for  full  literature,  vide  D.  J.  Leech, 

op.  cit.,  p.  1 80. 
311  Bradbury,  Brit.  Med.  Journ.,  1897,  vol.  i.,  p.  907.     See 

also  Brit.  Med.  Journ.,  1898,  vol.  i.,  pp.  18,  431  ;  and 

1899,    vol.    i.,    pp.    256,    ro88  ;    Russell,   Brit.  Med. 

Journ.,    1909,    vol.    ii.,    pp.    mo,     1314;    Brunton, 

Lancet,  1908,  vol.  ii.,  p.  1132. 

31  Lauder  Brunton,  International  Clinics,    1899,  Eighth 

Series,    vol.    iii.,    p.    in  ;    Huchard,    Maladies  du 
Cceur  et  de  f  Aorta,  1899,  3me  ed.,  vol  ii.,  p.  19. 

32  Lauder  Brunton,  Practitioner,  1905,- p.  735. 

3:5  Lauder  Brunton,  St  Barth.'s  Hosp.  Reports,  1883,  vol. 
xix.,  p.  329. 

34  A.  E.  Wright,  Lancet,  1897,  vol.  i.,  p.  303  ;  Luff,  Brit. 

Med.  Journ.,  1909,  vol.  i.,  p.  261  ;  Addis,  Brit.  Med. 
Journ.,  1909,  vol.  i.,  p.  999  (literature). 

35  Haig,  Diet  and  Food,  4th   ed.  (London  :    Churchill), 

1902. 
30  Oliver,  Blood  and  Blood-pressure,  2nd  ed.,   1908,  pp. 

210-n  ;  Barr,  Brit.  Med.  Journ.,  1905,  vol.  i.,  p.  57. 
37  Lauder   Brunton,  Clin.   Soc.  Reports,  vol.    iii.,   1870  ; 

reprinted  in  Collected  Papers,  First  Series,  p.  186. 
!R  Lauder  Brunton,  Lancet,  1906,  vol.  ii.,  p.   1330;  ibid., 

Birmingham  Medical  Review,  1909,  vol.  xiv.,  New 

Series,  p.  191. 
311  A.   E.   Wright,   Brit.   Med.  Journ.,    1891,  vol.  ii.,    p. 

1306  ;  1893,  v°l-  "•>  P-  223  >  '894,  vol.  i.,  p.  237,  vol. 

ii.,  p.  57  ;  Lancet,  1896,  vol.  i.,  p.  153,  vol.  ii.,  p.  807  ; 

1897,  vol.  i.,  p.  303  ;  1905,  vol.  ii.,  p.  1096  ;  Dixon, 


46o  LITERATURE 

Brit.  Med.  Journ.,  1909,  vol.  ii.,  p.  540 ;  Mayo 
Robson,  Lance/,  1902,  vol.  i.,p.  1024  ;  Lauder  Brunton, 
Brit.  Med.  Journ.,  1907,  vol.  i.,  p.  616  ;  J.  Barr, 
Brit.  Med.Joum.,  1907,  vol.  i.,  p.  717  ;  W.  Blair  Bell, 
Brit.  Med.  Journ.,  1907,  vol.  i.,  p.  920 ;  Addis,  Brit. 
Med.  Joum.,  1909,  vol.  i.,  p.  997  ;  Collingwood,  Brit. 
Med.  Journ.,  1910.  vol.  i.,  p.  507. 


INDEX 


NOTE  :  In  this  Index  the  references  to  figure*  are  to  the  pages  on  which  they 
appear,  and  not  to  the  numbers  of  the  figures  themselves. 


A.  S.,  and  V.  S.:  Significance  of  these 

letters,  60. 
A. V.  Bundle, see  Auriculo- Ventricular 

Bundle  or  Node. 
Abdomen,  Cold  Wet  Compress  to,  to 

induce  Sleep,  255. 

-  Constriction  of,  by  Corsets,  &c., 

Results,  227-8. 

-  Massage  of,  effects  of,  on  Digestion 

and  Expulsion  of  Gas,  238-9. 

-  Normal,  and  in  Advanced  Dropsy. 

(fig.)  352. 

-  Pressure  on,  from  Swollen  Thighs, 

234. 

-  Warm  Poultice  over,  action  of,  in 

Insomnia,  482. 

Abdominal  Aorta,  violent  Pulsation 
of,  177. 

-  Blood-vessels,  Effect  on,  of  Blow  on 

Intestines,  Goltz's  Experi- 
ment with,  on  Frog,  178, 
(fig.)  i&. 

—  Dilatation  of,  by  Warm  Poultice 
or  Compress,  482. 

-  Cavity,  Ascitic  fluid  in,  Absorption 

of,  promoted  by  Digitalis,  810. 

-  Contents  in  Upright  and  in  Supine 

Positions,  234,  (figs.)  235. 

-  Distension,    Causes    and     Effects 

of,  225-7 ;  on 

-  -  Heart,  229-30. 

-  -  Lungs  and  Heart,  239. 

-  Organs,    Motor    fibres   of    Vagus 

going  to,  67. 

-  Pain,  from  Iodides,  342. 

-  -  Poultices  for,  how  best  applied, 

255-7. 

-  Parietes,  Trocar  pushed  through, 

in  Tapping  for  Ascites,  261. 

461 


Abdominal  (cont.) 

-  Pulsation,  from  Abdominal  Irrita- 

tion, 177. 

-  Venous  Congestion,  Results,  225  et 


Abscess,  Cerebral,  Pulse-rate  with,  162. 

ABSOLUTE  Rest,  Why  Imperative  in 
Endocarditis,  369. 

Absorption,  Process  of,  393-4. 

Accelerator  Nerves,  64;  Stimulation 
of,  at  same  time  as  Vagus, 
effects  on  Ventricle,  69. 

-  -  Centre,  in  Medulla,  Excited  by 

Anaemia,  18. 

-  -  Fibres  of,  in  Vagus,  71,  267. 

—  of  Heart,  Function,  Origin,  and 

Route,  71-2. 
-  -  Effect  on,  of  Stimulation,  72. 

-  -  Systolic    fibres    (postulated)   in 

Frog's  Heart  innervated  by, 

Schmiedeberg's      hypothesis 

on,  270. 
Accessory,  Muscles   of  Circulation, 

11-12,  236-7. 

Acetate  of  Potassium,  as  Diuretic,350. 
Acetic  Acid,  for  Faintness,  422. 
Acid  in  Mucous  Membrane,  391 

-  Potassium   Tartrate,    as   used   in 

Imperial  Drink,  378. 

-  Secretion    in    Mouth,    Cause    of 

Headache  from,  447. 
Acidity  of  Stomach,  Action  of,  on 
Pylorus,  888. 

-  -  Cardiac  Irregularity  from,  382. 

-  -  Insomnia  from,  how  met,  430-1. 
Acids,  Effect  of,  on  Blood-vessels,  334. 
Acocanthera  (Oubain),  811. 
Aconite,  Action  of,  as  Cardiac  De- 

pressant, 328,  329. 


462 


INDEX 


Aconite,  Action  of  (cont.) 

—  in  Angina  Pectoris,  380. 

-  -  in  Reducing  Local  inflammation 

and  Pain,  253 ;  its  chief  use, 
829. 

-  -  on  Tongue,  828. 

-  -  as  Vasodilator  to  slow  Pulse,  839. 
Aconitine,  Action  on  (in  Frogs),  of 

Atropina,  Seasonal  Difference 
in,  282. 
Action  of 

-  Cardiac  and   Vascular   Remedies, 

266  et  sqq. 

-  -  Bibliography,  290  et  sqq. 

-  Drugs,  on  Circulation,  266-7. 

-  -  on  Frog's  Heart,  Investigation  of, 

by    Author  and    Bowditch, 

267  el  sqq. 

-  -  General    Rules   regarding,    273  ; 

considered  in  detail,  274  et 
tag. 

-  -  on     Urinary,     Digestive,     and 

Nervous  Systems,  346  et  sqq. 

-  -  Bibliography,  365. 

Activity  of  Heart,  Nutrition  of 
Heart  dependent  on,  155. 

Acute  Heart,  and  other  Diseases,  see 
under  Names. 

Adalin,  as  Hypnotic,  435-6. 

"Addison's  Disease,  Skin-colour  in, 
cause  of,  289-90;  and  the 
Suprarenal  Glands,  90. 

Adhesions,  Pleuro-pericardial  forms 
of,  Pulse  Indicative  of,  173. 

Adonis  vernalis  (Pheasant's  Eye), 
311. 

Adrenalin  or  Adrenin,  Action  of. 

—  Central  and  Peripheral,  Opposite 

Effects,  21,87,  276,  315. 

-  -  how  Differing  from  that  of  Pitui- 

trin,  819. 

-  -  on    Blood-presHure    and   Blood- 

vessels, 90,  323. 

-  -  Cerebral  and  other,  21. 

-  -  Coronary  Arteries,  333,  344. 

-  -  Heart  and,  315,  323. 

-  -  Peripheral  Veins,  87. 

-  -  Splanchnic  Arteries,  315,  333. 
Sympathetic  System  as  affected 

by    withdrawal   of    Normal 
Calcium  Salts,  279. 

-  Administration,    Effects    varying 

with  Mode  of,  315,  316. 

-  -  Intravenous,  in  Shock,  424. 

-  Chemical  constitution  and  Physio- 

logical   Action    of,    curious 
point  in,  315-6. 

-  Chloride,  in  Graves's  Disease,  416. 


Adrenalin  (cont.) 

-  Present  in  Normal  Blood  Serum, 

effects  of,  how  demonstrated , 
289. 

-  Vaso-constricting  powers  of,  Ex- 

ceptions to,  384. 

-  with  Cocaine,  as  Local  Anaesthetic, 

384. 

-  with    Ergot,  Rhythmic   Contrac- 

tions induced  by,  in  Strips 

of  Vessels,  88. 
Adults,  Effects  on,  of  Smoking,  and 

its  Attractions,  826-7. 
Aeration  of  Blood,  how  effected,  77  ; 

Heart's  Dependence  on,  151  ; 

Pulmonary,     Defective     in 

Cardiac  Dyspnoea,  196-7. 
Aesthetic    considerations     affecting 

use  of  the  Iodides,  340-1. 
..Etheris,  and  JStheris  Co.,  Spirit  of, 

as  Carminatives,  360. 
Afferent  and  Sensory  Nerves  of  the 

Heart,  64-5. 

After-Cure,  following  Nauhoim  Treat- 
ment, 249-50. 
Age,  see  also  Elderly,  Senile,  &c. 

-  Arterial  changes  in,  109-10,  126, 

132,  156,   199,  201-2,   (figs.) 

133,  184. 

-  in  relation  to  Causes  of  Giddiness, 

201,  423-4. 

-  in  relation  to  High  Tension  and 

Contraction    of   Capillaries, 
132,  (Jg.)ib. 
Age- incidence  of  Angina  Pectoris ,  190. 

-  Mortality  from  Disease  of  Blood- 

vessels and  Heart,  202,  208. 

Age-variation  in  Human  Blood- 
pressure,  109-10. 

Agurin,  Nature  and  Uses,  318. 

Air,  Need  of,  by  Fish,  18. 

-  Fresh,  Variable  demand  for,  14. 

-  Swallowing   of,  Flatulence   from, 

Causes  and  Treatment.  356. 

-  Swiss,  invigorating  action  of,  250. 
Air  Baths,  see  Hot. 

Air-beds  and  Pillows,  preferable  to 
Water-beds  and  Pillows,  872. 

Albumen  in  Urine,  Elimination  of, 
by  Combined  Rest  and 
Massage,  239. 

-  -  Presence  of,  not  Contra-indica- 

tiveofOpium,&c., in  Author's 

view,  865,  436-7. 
Albuminoid  bodies,  Toxins  derived 

from,  355. 
Albuminous  Substances  as  Cardiac 

Nutrients,  286. 


INDEX 


463 


Albumins,  Action  ou,  of  Digestion, 

393-4. 
-  Substances      derived     from,     see 

Turin  Bodies. 
Albumiuuria,    Bigeminal   Pulse    in, 


.         . 

-  Mercurials  in,  Danger  of,  exagger- 

ated in  Author's  view,  365,458. 

-  from  Mitral  Disease,  351,  (%.)352. 

-  from  Venous  Engorgement,  224  ; 

differentiated     from     other 

forms,  224-5. 
Aibumoses,  Production  of,  Poisonous 

Nature  of,  394. 
A!cohol(s),  Action  of,  on  Blood-pres- 

sure and  Blood-vessels,  433. 

-  -  in  Fainting,  422. 

-  -  on  Heart  and  Vessels,  335. 

-  -  on  Medusse,  36. 

-  -  Causing  Palpitation,  411. 

-  -  Selective,  on  the  Brain,  275. 

-  Contra-indicated  in  Graves's  Dis- 

ease, 415. 

-  Ingestion  ot    large    quantity    of, 

Causing  Speedy  Death,  178. 

-  Isopropyl,    experiment    with,   on 

Rabbit,  363 

-  Poison  of,  Bradycardia  from,  168 
Alcoholic  Neuritis,  Paralysis  of  Vagi 

from,  Pulse-rate  in,  168. 
Alcoholism.Chronic,  Fatty  Degenera- 

tion of  the  Heart  in,  151 
Aliphatic  Nitrites,  as  Vaso-dilators, 

339. 

-  Series,    Selective    Action    of,    on 

Btain,  275. 
Alkali  Metals,  Nitrites  of,  as  Vaso- 

dilators, 339. 
Alkaline  Treatment,  Advisable  with 

continued  use  of  Chloral,  434 
Alkalinity  of  Bowel  Contents,  Action 

of,  on  Pylorus.  388. 

-  of  Urine,  at  Gastric  Digestion,  391. 

-  -  in  Pyloric  Stenosis,  392. 

-  Increased  by  Blistering,  375-6. 
Alkalis,  Action  of,  on 

-  -  Blood-vessels,  334 

-  -  Chloral,  &c.,  434-5. 

-  Gastric    Acidity,    356-7,    887-8, 

420,  431. 

-  -  Secretion  of  Gastric  Juice,  887-8. 

-  Tachycardia,  Process  of,  857. 
Alkaloids,  Antagonistic,  in  Muscarine, 

278. 

Allen  &  Hanburys,  Messrs.,  Bottle 
made  by,  for  Author,  for 
Administration  of  Medicated 
Oxygen,  241-3. 


Aloes,  in  Senile  Conditions  of  Blood- 
vessels, 458. 

Alpha-naphthol,  as  Gastric  Anti- 
septic, 356. 

Alpine  Climbing,  False  Angina  from, 
198. 

Altitudes,  in  relation  to  Discomfort, 
in  Cardiac  Disease,  250. 

Amines,  Similar  in  Action  to  Supra- 
renal  Extract,  Sources  of,  90, 
91  &n. 

Amino-acids,  Production  and  Nature 
of,  394. 

Ammonia,  as  Cardiac  Stimulant  in 
Endocarditis,  how  given,  377  ; 
Heat  Stoppage  in  Animals 
from  Inhaling,  73. 

-  Aromatic  Spirits  of,  alone   or   in 

Combination. 

-  -  in  Acute  Rheumatism,  874. 

-  -  as  Carminative,  360,  361. 

-  Bromide  of,  alone  or  in  Combina- 

tion, in 

-  -  Graves's  Disease,  416. 
•  -  -  Insomnia,  432. 

-  -  Palpitation,  413. 

-  Carbonate,    to   Abort   attacks   of 

Stokes-Adams  Disease,  421 ; 
in  Faintness,  422. 

-  Hippurates  of,  in  Angina  Pectoris, 

Action  of,  443 ;  in  Senile 
High  Tension,  454. 

-  Intestinal  Poisons    aHied    to,  re- 

sulting from  Digestive  Pro- 
cesses, 394. 

-  Liniment     rubbed    over    Cardiac 

Region,  Palpitation  induced 

by,  2C3. 
Ammonia;      foetidus,    Spiritus,     as 

Carminative,  860. 
Ammoniated  Mercury  Ointment  for 

Eruption-Pustules     due    to 

Iodides,  342. 
Amoeboid  Dendrons  of  Brain  cells, 

Powers  of,  and  Susceptibility 

to  Stimuli,  425. 

-  Nature  of  Dendrons  of   Neurons, 

200  n. 

Amyl  Nitrite,  Central  and  Peri- 
pheral Action  of,  aiding  each 
other,  276. 

-  -  First  used  in  Angina  Pectoris  by 

Author,  258,  260,  336-8,  454 ; 
his  personal  experience  with 
it,  335  et  sqq. 

-  -  How  best  given  with  Oxygen,  in 

Angina  i  ir  Spasmodic  Asthma, 
241-3,  445,  (figs.)  242,  248. 


464 


INDEX 


Amyl  Nitrite  (cont.) 

-  -  Inhalation  of,  producing  Bigemi- 

nal  Pulse,  171. 

-  -  Use  in  Attacks  of  Anginal  Pain, 

441,(/tys.)192, 193. 

-  -  Vaso-dilating  Action  of,  260,  276, 

332,  889,  843,  344. 
Anaemia,  Bradycardia  in,  167. 

-  Cardiac  Dilatation  in,  217. 

-  Cerebral,  in  Sleep,  868 ;    in  Syn- 

cope, 180. 

-  Chronic  and  Acute,  Fatty  Degenera- 

tion of  the  Heart  in,  151. 

-  Effects  of,  on  Centres  in  Medulla, 18. 

-  Iron  with  Pulvis  Mirabilis  for,  440. 

-  Palpitation  associated  with,  Treat- 

ment, 414. 
Anaesthesia,  Imperfect,  as  Cause  of 

Shock,  179,  424. 
Anesthetics,    Local,    Cocaine    with 

Adrenalin  as,  Mode  of  action 

of,  884. 

-  -  Ether  Spray  for  use  in  Tapping 

for  Ascites,  261. 

-  Tight-lacing     Dangerous     during4 

giving  of,  227-8. 

Aneroid     form    of    Sphygmomano- 

meter,  104, 105, 114. 
—  Standardisation  of,  105. 

Author's   apparatus   for,  (fig.) 

106. 

Anethum,  Oil,  and  Water  of,  as  Car- 
minative, 860. 

Aneurism,  Abdominal  Pulsation  sug- 
gesting, 177 ;  X-ray  diagnosis 
of,  188. 

-  Aortic,    Accentuation   of   Second 

Sound  from,  210-11. 

-  Cardiac,  Treatment,  454-5. 
Anger,  Angina  Pectoris  from,  Histori- 
cal case,  189. 

Angina  Abdominis,  Author's  (and 
others')  cases  of,  195. 

-  -  Attacks,  and  Treatment,  444. 

-  -  Names  given  to,  195-6. 
Angina,  False,  from   excessive    To- 
bacco-smoking, 193. 

Angina  Pectoris,  423. 

-  -  Attacks   of,    Treatment   of,  see 

Aconite,  Amyl  Nitrite, Bleed- 
ing Carminatives,  Nitrogly- 
cerin,  <ftc. 

-  -  in  Aortic  Disease,  407. 

—  Claudication  in,  Views  of  Burns 

and  of  Brodie,  193-5. 

—  Diet  and  Regimen  in,  448-4. 
Flatulence  to  be  Avoided  by, 

189,  442,  443. 


Angina  Pectoris  (cont.) 

-  -  Difficulty  of  makingObservations 

in,  Author's  recorded,  191-2, 
(figs.)  192-3. 

--Liability  in,  to  Sudden  Death,    , 
189,  404. 

-  -  Oxygen,  with  Nitrite  of  Amyl,  or 

Iodide  of  Ethyl  in,  how  given, 
241-8,  (figs.)  242,  243. 

-  -  Pains  of,  Location  and  Causes, 

94, 188-9  etiqq.,  219,403. 

Pains     resembling,     in      the 

Healthy,  Causes,  193. 

-  -  Pathology,  189-93,  (figs.)  192-8. 

-  -  Pulse  in,  192-3,  (Jigs.)  192, 198. 

-  -  Sensations  frequent  in,  see  also 

Pain. 

(a)  Intense  Oppression,  188-9. 

(6)  Extreme  Pain,  Nature  of,  in 

Author's  view,  188-9  et  sqq. 
Angina    Pectoris,    Pseudo-gastrique, 

see  Angina  Abdominis. 
Angio-neurotic      (Edema,      Nature, 

Symptoms,     and     probable 

Causes,  198-9,  310. 

Animal  ' '  Bled  into  its  own  Veins, "  10. 
Animals,  Blood-pressure  in,  Mode  of 

Measuring,  95-6. 

-  Heart-stoppage  in,  from  Irritation 

of  Nasal  Mucous  Membrane, 
73. 

-  Poisoned  by  Digitalis,  Apex-beat 

in,  Increased,  175-6. 

-  Slow    Pulse    in,     producible     by 

Irritation  of  Vagus,  167. 
Anise,  Oil,  Spirit  and  Water  of,  at* 

Carminative,  SCO. 
Annoyance,    EHect    of,    on    Blocd- 

pressure,  112. 
Annulus  of  Vieussens,  71. 
Antacids,  356-7. 
Anthemidis,  Oil  of,  as  Carminative, 

860. 

Antiaris  toxicarla  (Upas),  811. 
Antifebrin  in  Endocarditis,  376-7. 
Antikamnia,  for  Headache,  448. 
Antipyretic  action  of  Morphine,  on 

Pigeons,  284. 
Antipyrin,      between     Attacks     of 

Angina  Abdominis,  444. 

-  in  Endocarditis,  376. 

-  for  Headache,  448. 

-  Overdose  of,  effect  on  Pulse,  437. 

-  with  Caffeine,  in  severe  Headache 

with  Vomiting,  448. 
Antiseptic  action  of  Normal  Gastric 

Juice,  355. 
Antiseptics,  Gastric,  355,  356,  374. 


INDEX 


465 


Anti-streptococcic  Serum,  Universal 

(Edema  from,  199. 
Anti-thyroid  Serum,  in  Graves's  Dis- 

ease, How  Best  Given,  417. 
Antitoxin,    Diphtheritic,    Urticarial 

rash  from,  199. 
Antra,     Nasal,     Inflammation     of, 

Headache  from,  447. 
Anxiety,  in  Angina  Pectoris,  189. 
Aorta,  Abdominal,  Pulsation  in,  177. 

-  Calcification  of,  211. 

-  Circulation  into,  26. 

-  Contractile  Power  of,  84. 

-  Dilatation  of,  Second  Sound  with, 

211. 
.  -  Heart  cut  off  from,  during  Rest,  6, 


-  High  Tension  in,   Second   Sound 

Accentuated  by,  210-11. 

-  Impulse   given    by,  to   Blood   in 

Vena  Cava  Inferior,  9. 

-  Ligature  of,    as    affecting   Blood- 

pressure,  19. 

-  Low  Tension  in,  First  Sound  in 

Weak  Heart  with,  212. 

-  Resistance  from,  to  Left  Ventricle, 

78,  (fig.)  166. 

-  Storage  Action  of,  7. 

-  Structure  of,  84. 

-  Ventricular  Contraction  as  affect- 

ing, 9. 

Aortic  Atheroma,  Cardiac  Murmurs 
due  to,  Common  in  the 
Elderly,  214. 

—  Indicated    by   Accentuation    of 

Second  Heart  Sound,  210-11. 

-  Bulb,  Frog's  Heart,  20. 

-  Disease,  Fluid-quantities  allowed 

in,  by  Schott,  251. 

-  -  Cardiac  Pain  in,  407. 

-  Obstruction,  Cardiac  Murmurs  due 

to,  214. 

-  Pressure,  in  relation  to  outflow  of 

Arterial  Blood,  146. 

-  -  Rise    of,  Effect  on  Valves,  125, 

(fig.)  124. 
---  Extra  Systole  due  to,  171. 

-  Pulse,  Slow,  Causes  (fig.),  166. 

—  Tracings  of,after  Marey  (fig.),  124. 

-  Regurgitation,  Arterial  Pulsation 

Observable    in,    Coincidence 
in,  of  the  three  Rhythms,  88. 

-  -  Cardiac  Murmurs   in,   213,   214, 

Where  Heard,  403. 

-  -  Causes,  215. 

-  -  Dilatation  from,  217. 
•  -  Effects,  218-9. 

-  -  Experimental,  in  Rabbits,  406. 


Aortic  Regurgitation  (cant.) 

—  Faintness  in,  Risks  of,  and  Treat- 

ment ,  423. 

-  -  Flow  of  Blood  in,  218. 

-  -  Full  Diet  advised  in,  by  Schott, 

250. 

-  -  Process  of,  Effect  on  Sphygmo- 

grams,  130,  (Jig.)  ib. 

—  Pulse  in,  Tracing  showing  Hook, 

130,  (fig.)ib. 

-  -  Risk  of  Sudden  Death  in  ;  pre- 

cautions as  to  Identification 
and  Avoidance  of  Sudden 
Strain ,  &c.,  404. 

-  -  Special   Dangers  of,  404  et  sqq., 

(fig.)  405. 

-  -  Treatment,  405-6,  428. 

-  Stenosis,    Cardiac     Murmur     In- 

dicating, 214. 

-  -  Cause,  215. 

-  -  Effects,  218. 

-  -  Treatment,  402-3. 

-  Valves,  Functional  Regurgitation 

in,  215. 

-  -  Functions  of,  6,  (fig.)  ib. 

—  Incompetence  of,Cardiac  Murmur 

Indicative  of,  213,  214,  403, 
(fig.)  75. 
and  Dichrotic  Pulse,  131. 

-  -  Second  Heart  Sound  made  by,  76, 

and  well  Heard  over,  77, 
Effect  on,  of  Asynchronous 
Closing  of  Pulmonary  and 
Aortic  Valves,  211. 
Aperients,  see  also  Calomel,  Mer- 
curials, Purgatives,  Salines, 
and  under  Names. 

-  in  Angina  Pectoris,  443. 

-  in    Senile    Conditions    of   Blood- 

vessels, 453. 

Apex    of    Heart,    and    Palpitation, 
76,  226, 412. 

-  -  Contraction  of,  55. 

-  in  Frogs,  as  affected  by  Stimuli, 

29-80,  35. 

-  -  First  Heart  Sound  Best  Heard 

Over,  77. 

-  Pain  over,  Causation,  Relative  Im- 

portance, Treatment,  187-8. 

-  Systolic  and  Pre-systolic  Murmurs 

heard  at,  Indications,  214-15, 
218. 

Apex-beat  in  Animals,  Effect  on  of 
Digitalis  Poisoning,  176-6. 

-  Diminution  or  Absence  of, Symptom 

of  Pericarditis,  877 

-  in  Palpitation,  Increase  of  Force 

of,  175-6. 


466 


INDEX 


Apex-beat    Cardiograms,    How    Ob- 
tained, 126,  (figs.)  126,  187. 
Aphasia,  Causes,  145,  -205. 

-  with  Migraine,  Author's  Observa- 

tion, 186. 
Apocynum     cannabinum    (Canadian 

Hemp),  811. 
Apoplexy,  Bradycardia  from,  166. 

-  Causes,  16. 

--  Cerebral,  How  to  Avert,  454. 

-  Bisk  of,  in  Bright's  Disease,  with 

use  of  Digitalis,  318. 

-  -  Lessened  by  Safety-valve  Action 

of  Left  Ventricle,  78. 
Apparatus  for  Artiticial  Circulation, 
in  Mammalian  Vessels,  271-2 

-  for  Investigating  Action  of  Drugs 

on  Frog's  Heart,  and  Ven- 
tricle, described,  267-9. 
Appetite,    Effect    on,  of  Disordered 
Circulation,  229 

-  Improvement  of,  by  Massage  and 

Rest,  238. 

Arm(s)  Bleeding  from,  When  Useful, 
Methods  of,  259-60. 

-  Exercises  for,  in  Nauheim  Treat- 

ment,   245,     248;     in     Best 
Treatment,  239-40. 

-  Left  free  in  Wet  f  ack,  Why,  432. 
Armlet     Sphyginomanometer,     104, 

107 ;    Mode   of    use,    107-8 ; 
Fallacies  of,  108-9. 
Aromatic  Series,  Toxins  of,  855. 

-  Spirits    of    Ammonia,    see   under 

-  Ammonia. 

-  Vinegar,  for  Faintness,  422. 
Arrow-poisons,  Plants  Yielding,  Con- 
geners of  Digitalis,  311. 

Arrowroot  Poultices,  255. 
Arsenic,  Fatty  Degeneration  of  Heart 
induced  by,  151. 

-  with  Iodides,  Why  Given,  842. 

-  and  Iron,  in  Anaemia  Palpitation, 

414. 

-  and  Strychnine  Solution,  in  Bay- 

naud's  Disease,  450. 
Arterial  Circulation,  7,  8,  9. 

-  Contraction  Caused  by  Adrenalin, 

How  Demonstrated,  289. 

-  -  in  relation  to  Chronic  Interstitial 

Nephritis,  92. 
-  and  Dilatation,  in  Migraine,  184. 

-  -  effects  on  the  Senses,  1S5-6. 

-  Distension,  due  to  High  Arterial 

Tension,  as  in  Bright's  Dis- 
ease, 126,  (fig.)  118. 

-  Obstruction,  Causes  and  Besults, 

186. 


Arterial  (cent.) 

-  Pulse,  Effect  of,  on  outward  flow  of 

Venous  Blood,  &c.  (fig.),  10. 

-  Sheath,  Contents  and  Action  of, 

10,   156-7,    286-7,    (figs.)    10,    * 
156,  157. 

-  Spasm,     of      Cerebral     Arteries, 

Functional  Motor  Disturb- 
ance due  to,  186. 

-  -  False  Angina  from,  193. 

-  -  in  Baynaud's  Disease,  197. 

-  Tension,  fee  also  Blood-pressure. 

-  -  Diagnosis  of,  Means  of,  145-7. 

-  -  in  Angina,  Treatment  to  Lessen, 

443. 

-  -  in  Aortic  Stenosis,  Lowering  of, 

Means  for,  403. 

-  -  in  Dog,  as  affected  by  Digitalis, 

and  by  Electrical  Stimulation 
of  Vagus,  299,  301,  (.fig*.) 
299-300. 

-  -  Effect  on,  of  Disease  of  Medullary 

Portion  of  Suprarenal  Gland, 
289. 

-  -  High,  Causes,  and  Action  of,  on 

Vagus  Boots,  How  Lowered 

in  Bradycardia,  420. 
Abnormally   so,    as  Cause    of 

Insomnia,  364. 
Safety-valve    Action    in,    of 

Left  Ventricle,  78. 
Bradycardia  due  to,  166. 

-  -  Cheese  of  Value  in  Diet  in,  389. 

-  -  Continuous,   Headaches    with, 

forgotten  by  Patients,  447-8  ; 
Treatment,  448. 

-  -  Lofty  Altitudes  to  be  avoided 

in,  250. 

Means  of  Believing,  see  Amyl 

Nitrite,  Bleeding,  Nitro- 
glycerine, <£c. 

Not    altogether    Undesirable, 

451-2. 
-  ViscosityofBloodasaCause,147. 

-  -  Low,  Causes  and  Treatment,  181, 

828,  413,  451. 

-  -  Measurement    of,    100    et    sqq. 

See  Blood-pressure  in  Man, 
Measurement  of. 

-  -  and      Pulse-pressure,      relation 

between  (fig.),  118. 

-  -  Bise  of,  from  Digitalis,  Blake's 

Discovery,  295. 

-  -  on  What  Dependent,  16, 146. 

-  Thrombosis,  Effects,  186. 

-  Walls, Degeneration  of,  in  the  Aged, 

Nature  and  Besults  of,  199, 
200,  204-5. 


INDEX 


467 


Arterial  Walls,  Degeneration  (cont.) 

Oscillations  in,  as  affected  by 

Slow  and  Quick  Pulse,  115 
«t«WM(«p«.)110,  117. 

Noted  in  Measuring  Diastolic 

Pressure,  114-15. 

-  -  Significance  of,  118. 
Arterio-capillary  Fibrosis,  of  Gull  & 

Sutton,  199. 
Arterioles,  Action  on,  of 

-  -  Adrenalin,  90,315. 

-  -  Caffeine,  276. 

-  -  Digitalis,  299-301,  307,  (fig.)  117. 

-  -  Discovered  by  Traube,  295-6. 

-  -  Nicotine,  323. 

-  -  Toxin,  200. 

-  Circulation  in,  8,  9. 

-  Compression  of,  from  Mitral  Dis- 

ease, 351,  (jig.)  352. 

-  Condition,  as  Shown  by  Sphygmo- 

graph,  138. 

-  Contractility  of,  Use  of,  14,  15 ; 

Causes,  I6,andsee  Action  on, 
of  Drugs,  above. 

-  -  Independent,    8 ;   Author's    Re- 
searches on,  271-2. 

-  Contraction,  Chronic,  and  Thicken- 

ing of,  as  Causes  of  Chronic 
Interstitial  Nephritis,  92. 

-  Dilatation  of,  Observations  on,  of 

Author  and  others,  87. 

-  Local     Irritation     of,     Author's 

(and    others')    Observations 
on,  87. 

-  Lumen  of,  Lessening  of,  Risks  of, 

and  some  Causes,  199. 

-  Size,  in   Relation   to   Outflow   of 

Arterial  Blood.  146. 

-  Structure,  84 ;  Nerve  Fibrils  in,  85, 

(fig.)  tb. 

Arteriometer,  Oliver's,  for  Measuring. 
Size  of  Arteries,  118-19. 

Arterio-Sclerosis,  Indicated  by  Per- 
manent Accentuation  of 
Second  Sound,  211. 

-  Diffuse,  Nature,  Causes,  and   Re- 

sults, 199. 

-  Iodides  in,  Prescription  for,  342. 
Artery(ies),  see  also  under  Names. 

-  Aneurism  of,  Treatment,  454-5. 

-  Atheromaof  ('/.«.)•  Prognosis,  156  ; 

Results,  199. 

-  Condition  of,  in    Migraine,  183-5, 

(fig.)  184. 

-  Contractile  power  of,  7,  8,  9,  15. 

-  Contraction     of,     Unequal,     and 

Blood-pressure,  18. 

-  in  Diastole,  154. 


Artery(ies)(«>7U.) 

-  Distention  of,  Effect  of,  on  Venous 

Circulation,  10. 

-  Distribution  of,  in  Brain  (fig.),  205. 

-  Effect  on,  of  Heat  and  Cold,  92,  98 ; 

of  Stimulation  of  Connected 
Muscles,  397. 

-  Elasticity   or    Elastic   Recoil   of, 

Function  of,  7-9,  14-15. 

-  -  Age-,  Sex-,    and   Race-variation 

in,  109-10,  126,  132,  156,  199, 
201-2,  (figs.)  133,  134. 

-  -  How  Shown  by  Sphygmograph, 

138. 

--Emptiness  of,  after  Death,  3,  8, 
13,  19. 

from  Gastric  or  Intestinal  Irri- 
tation, 178. 

from  Shock,  178. 

Results,  129. 

-  Irritability  of,  in  Aortic  Regurgi- 

tation,  219,  cf.  88. 

-  Lumen  of.Degeneratiou  of,  Results, 

204. 

-  "  Man  as  old  as,"  Truth  of  Saying, 

156,  201. 

-  Massage  by,  of  Nerves,  in  Health, 

236-7. 

-  Muscular  Fibres  of,  Action  on,  of 

Digitalis,  298. 

-  Muscular   Layer  of,  Nerve-fibrils 

over,  53,  85,  (fig.)  85. 

-  Obliteration  of,  Causes  and  Conse- 

quences, 204-6. 

-  Pulsation  of,  Periodical,  88. 

-  Rigidity  of,  as  Affecting  Results 

with  Armlet   Sphygmoman- 
ometer,  108-9  ;  Signs  of,  162. 

-  Sectional  Shape  of,  in  Health,  128-9. 

-  Self-massage  of,  10-11,  156-7,  237, 

(figs.)  10, 156. 

--Effect  on,  of  Digitalis,  309;  of 
Massage,  238,  and  Exercises, 
240. 

-  Sensitiveness  of,  184-5. 

-  Size  of,  Instrument  for  Measuring, 

devised  by  Oliver,  118-9. 

-  Structure  of,  84 

-  Triple  Function  of,  6-8. 

-  -  Motor  and  Peristaltic,  7,  8. 

-  -  Regulating,  7. 

-  -  Storage,  7. 

-  and  Veins,  Common  Sheath  of.Uses 

of,  10,  (fig.)  156. 

Artificial  Circulation,  see  also  Circu- 
lation, and  under  Frog's 
Heart. 

-  -  after  Death,  Effects,  12-13. 


468 


INDEX 


Artificial  Circulation  (cont.) 

-  -  Invention  of,  by  Ludwig,  Results 

of,  267. 

-  -  in     Mammalian     Blood-vessels, 

Apparatus  for,  271-3. 

-  -  Rhythmic  Pressure  in,  11. 

-  Respiration ,  with  Oxygen  ;  When 

Performed,  Instrument  for, 

248,  (fig.)  248. 

Asafcetida  as  Carminative,  301. 
-Compound,  for  Flushes  of  Heat 

and  Blushing,  449. 
Ascites,  tee  alto  Effusion,  <t  (Edema. 

-  Abdominal,  Effect  on  Ureter,  Tap- 

ping to  Overcome,  261-2,  (ftg.) 
262,  352. 

-  Action  in,  of  Digitalis,  310. 

-  -  of  Massage  &  Rest,  289. 

-  in    Cardiac    Diiease,    Fluid   Loss 

and  Gain  in,  808. 

-from  Venous  Congestion  Usually 
Accompanied  by  Flatulence, 
Effects  on  Heart,  225-8. 

-  from  Venous  Engorgement,  224-5. 
Asphyxia,  Pulse  in,  18. 

-  Local,  see  Raynaud's  Disease. 
Aspiration  for  Pericardial  Effusion, 

377. 
Aspirin  for  Headache,  448 ;  Overdose 

of,  Effect  on  Pulse,  437. 
Assimilation,  Effect  on,  of  Digitalis, 

311 ;  Process  of,  393-4. 
Asthma,  Cardiac,  Causes,  Treatment, 

444-5. 

-  Spasmodic,  Oxygen,   with  Nitrite 

of  Amy  1,  or  Iodide  of  Ethyl, 

for,  241-3,  (Jigs.)  242,  243. 
Astigmatism,  Headache  from,  446  ; 

Migraine  from,  183. 
Atheroma,  Aortic,  Accentuation  of 

Second  Sound  due  to,  210-11. 

-  -  Cardiac  Murmurs  due  to,  in  the 

Elderly,  214. 

-  of  Carotids,  Insomnia  from,  how 

Relieved,  432. 

-  of  Arteries,  Prognosis  of,  156  ;  Re- 

sults, 186,  199. 

-  in  Blood-vessels,  92. 

-  of  Coronary  Arteries,  Results,  96, 

153-4,  182,  184. 

-  -  Seriousness  of,  214. 

-  Giddiness  from,  201,  423. 

-  Nodular  Form,  Effects,  190. 

-of  Right  Pulmonary  Artery,  Re- 
sults, 228. 

Atheromatous  Change  in  Arteries  in 
Old  Age,  Results,  126,  199. 
200,  202 


Atrophic   Degeneration,   caused   by 

Section  of  one  Vagus,  160. 
Atrophy,  Brown,  Causes,  158. 
Atropine,  Action  of,  on,  and  in 

-  -  Drups,  in  Frogs,  and  on  Frog's 

Heart,  Seasonal   Differences  > 
in,  281-2. 

-  -  Large,andinSmallDoses,274,277. 

-  -  Nerves,  Paralysing  Effects,  274. 

-  -  Vagus  Nerve,  Effects  of,  71,  274 ; 

and  High  Pulse-rate,  163; 
Utilised  to  Avoid  Operative 
Shock,  424;  and  in  Stokes- 
Adams  Syndrome,  169,  421. 

-  -  Ventricular  Contraction,  Differ- 

ing with  Temperature,  282. 

-  Determination  by,  of  Existence  of 

Accelerating  as  well  as  In- 
hibitory Fibres  in  Vagus 
Nerve,  267. 

Auditory  Centre,  Disturbance  of,  by 
Arterial  Contraction,  186. 

-  Disturbance  from  Obstruction  of 

Sylvian  Artery,  205. 

Aural  Conditions,  Causing  Head- 
ache, 447. 

Auricles,  Action  on,  of  Vagus,  66,  69. 

-  Contraction  of  Heart  begun  in,  55  ; 

Gallop  Rhythm  probably  due 
to,  212 

-  Dilatation  and  Hypertrophy  of,  in 

Relation  to  Venous  Engorge- 
ment, 228-4. 

-  in  Frog's  Heart,  25,  26. 

Deductions  on,  from  Stannius's 

Experiments,  40-2,  (figs.)  41. 
Refractory     Period    of,     44-5, 

(fig*.),  43 
Stimulation  of,  Effects  on  Beats 

of    Auricle    and     Ventricle 

(figt.),  45. 

-  Hypertrophy  of,  Causes  of,  221. 

-  Left,  Effect  on,  of  Over-high  Blood- 

pressure,  18. 

-  in  Mammalian  Heart,   Propulsive 

Action  of,  25. 

-Stimulation  of,  Constant,  in 
Mitral  Obstruction,  Results, 
220,  222. 

Auricles  and  Ventricles,  Action  of, 
when  one  Vagus  is  Stimu- 
lated, 65-6. 

-  Conduction  between,  Interference 

with,  Heart-block  du  to,  59. 

Path  of,  28,  81,  69;   Time  of 

passage  of,  as  affected  by 
Stimulation  of  Vagi,  145, 


INDEX 


469 


Auricles  and  Ventricles  (<xmt.) 

-  Effect  on,  of  Ligaturing  the  Heart, 

40<t  sqq.,  (figs.)  41. 
Auricular  Beats  in  Frog's  Heart  as 
affected  by  Stimulation,  45, 
(fig.)  45. 

-  Canal,  57. 

-  Extra  Sound,  causing  Reduplica- 

tion of  First  Heart  Sound,212. 
Auricular    Fibrillation,    Effects    of, 
68,  66 ;  apparently  present  in 
•  Tachycardia,  165. 

—  in  Man,  Detection  of,  Means  of, 

139  &n.,  140  et  sqq. 

-  Systole,  137. 

Anriculo  -  ventricular  Groove,  in 
Frog's  Heart,  Effect  of  Com- 
pressing, 31-2. 40,  58,  (fig.)  32. 

-  Node,  or  A.V.  Xode,  57. 

—  Lesion  of,  Stokes- Adams  Disease 

from,  Treatment,  421. 

-  -  Rhythm,  initiation  by,  58,  cf.  30 ; 

Enfeebled,    Impulses    from, 
action  of,  on  Pulse,  437. 

Interval  in,  variations  in,  with 

compression    of    Bundle    of 
His,  60. 

—  Transmission  through,  of  Stimuli, 

Mode  of,  possibly  Chemical, 
286. 

-  Orifices,  Effect  on,  of  Mitral  In- 

competence, 220-1. 

-  in  Health  and  with  Dilated  Heart, 

215. 

-  -  Muscular  Rines  round, 

Benefit  to,  from  Digitalis,  809. 

Contraction    of,   Aid    of,   to 

Heart  Valves,  75,  (fig.)  ib. 

-  Systole,   Changes   in,  from  Com- 

pression of  Bundle  of  His,  60. 

-  Valves,     Flapping     together     of, 

Sound  of,  76,  77. 
Auscultation,   Measurement   by,  of 

Diastolic  Pressure,  113. 
Autocoid    Substances,    Xature    and 

Functions,  893. 
Autointoxication,  Xature  and  Causes, 

394. 

BACK,  Wet  Cupping  over,  in  Suffo- 
cative  Bronchitis,  258. 

Bacilli  and  Cocci  causing  Cardiac 
Inflammations,  151-2. 

Bacillus  butyricus,  action  of,  359. 

-  Diphtheria,    Effect  of,    on    Myo- 

cardium and  Vagus,  152, 160. 

-  Influenzas,     Effect    of,    on    Myo- 

cardium and  Vagus,  152. 


Bad  Taste  in  Mouth,  Wash  to 
Remove,  426. 

Baden weiler,  Graduated  Walks  at, 
249. 

Band  Sphygmomanometers.  102,  103 
et  sqq. 

Bandages,  Cold,  covered  with  Oil 
Silk.  Benefit  of,  in  Local 
Inflammation,  254-5. 

Bandaging  Painful  Joints  in  Rheu- 
matic Fever,  371. 

Barclay,  Captain,  Walking  Feat  of, 
5,  6. 

Barium,  Action  of,  on  Heart  and 
Vessels,  334. 

-  -  as    affected    by    Climate,    and 

Temperature,  283. 

-  -  Counteracted    by    Potash    pre- 

viously as  well  as  presently 
Administered,  278-9. 

-  Chloride,  Action  of,  on    Outside 

and  on  Inside  of  Frog's  Ven- 
tricle, 270. 

Basch,  von,  Sphygmomanometers  of, 
101,102;  Modes  of  Using,  107. 

Base  of  Heart,  Contraction  of,  65. 

—  Xerve  Plexuses  around,  63. 

—  Xet-work  at,  Xerves  passing  to, 

64. 

Bathomotrope,  56. 
Baths,  see  also  Hot,  and  Warm. 

-  for  Increasing  Pulse-vigour,  157-8. 

-  in  Xauheim  Treatment,  Results, 

244,  403,  (figs.)  246,  247. 
Batscha  Harbour,  Wave- Interference 

at,  37. 
Bed,    Getting    into,   Strain   of,    on 

Heart,  233,  236. 

-  Cooling,  to  Relieve  Insomnia,  427-8. 

-  Position  in,  in  relation  to  Night- 

mare and  Palpitation,  412. 

-  Rest  in,  in  Graves's  Disease,  415, 

416. 

—  in  Heart  disease,  Length  usual 

now,  and  formerly,  368,  369. 
Bedclothes,  Heavy,  and    Insomnia, 
427. 

-  for  Rheumatic  Fever  Patients,  370. 
Bed-pan      for      Rheumatic      Fever 

Patients.  370. 

Bed-sores,  as  Cause  of  Insomnia,  429. 
Beds,  for  Rest  Treatment,  235-6. 

-  for    Rheumatic    Fever    Patients, 

371-2. 

Beef-tea,  Effects  of  Barium,  Frog's 
Muscle  counteracted  by,  279. 

-  in  Cerebral  Thrombosis,  456. 

-  Stimulant  Value  of,  288. 


470 


INDEX 


Belladonna  in  Grave's  Disease,  416. 
Belladonna  Plaster,  as  Local  Cardiac 

Sedative,  263,  413,  (fig.)  268. 
Benzoate  of  Soda,  in  Septic  Endo- 

carditis and  Pericarditis,  878. 
Benzoates,    as    Vasodilators,     389, 

Action  on  Kidney,  340. 
Benzoic  Acid,  Hippuric    Acid   con- 

verted  into,  in  Renal  Disease, 

91  ^w. 
Beta-naphthol,  as  Gastric  Antiseptic, 

856. 
Bicarbonate  of  Potassium  with  Milk, 

in  Rheumatic  Fever  Diet,872. 

-  Soda,    Action    of,    in    Lessening 

Dyspepsia,  387. 

—  in   Carminative    Compounds   in 

Relief  of  Pulse  Irregularity, 
861,  438-9. 

—  with  Laudanum  as  Mouth  wash, 

for  Headache,  447. 

-  -  with  Milk  in  Rheumatic  Fever 

Diet,  872. 

-  -  Motithwash  of,  for  Aching  Teeth, 

426. 

-  -  for  Stomach  Acidity,  How  Best 

Given,  356-7. 
Bicarbonates,  Carminative  Action  of, 

887. 
Bicycling.  Restrictions  on,  for  Cardiac 

Patients,  252. 
Bidder's  Ganglia,  in   Frog's  Heart, 

26,  56  ;  and  Origin  therein  of 

Siirnuli,  30,  81. 
Bigeminal  Pulse,  169;  Causes,  170-1, 


Bile,  Action  on,  of  Mercurials  and 
Purgatives,  353-5. 

-  Secretion  and  Expulsion  of,  395-6. 

-  -  External,  by  Liver,  89. 

-  and  Toxins,  Retention  of,  in  Body, 

Results,  354-5,  (fig.)  354. 
Bile  Acids,  Weakening  Effect  of,  on 

Cardiac  Muscle,  Bradycardia 

due  to,  1(58. 

Biliousness,  Exercises  in  Relief  of,396. 
Bismuth,    iu     Bradycardia,      When 

Indicated,  420. 

-  in  Catarrh  of  Mucous  Membrane, 

390. 

-  in  Paroxysmal  Tachycardia,  When 

Indicated,  41  9. 

-  Ointment  of,  for  Pruritus  Ani,  430. 

-  as  Stomach  Sedative,  856. 

-  with  Hamaraelis,  in  Suppository 

for  Pruritus  Ani,  429. 
Bitartrate  of  Potash,    with   Jalap, 
Diuretic  Action  of,  858. 


Bitters,  Value  of,  in  Dyspepsia,  8e8. 
Bladder,     see    Gall     Bladder,     and 

Urinary  Bladder. 
Blake,   James,    Experiments  of,  on 

Digitalis  Action,  295.  I 

Blankets,  not  Sheets,  for  Rheumatic 

Patients,  370. 
Bleeding : 
-General,  from    the  Arm,  254-60; 

When  of  Use,  258-9,  389,  454, 

455. 

-  Local,  by 

-  -  Cupping. 

Dry,  258. 

Wet,  ib. 

-  -  Leeches,  257-". 

-  Repeated,  When  Advisable,  260. 
Blindness,  Partial,  from  Obstruction 

of  Sylvian  Artery.  205. 
Blisters,    for    Cardiac    Pain,    Place 
for  applying,  441. 

-  for  Headache   following   Cerebral 

Haemorrhage,  456. 

-  for  Pains  of  Acute  Rheumatism, 

868,  375. 

-  in  Pericarditis,  Position,  Sire,  Use, 

263,  377. 

-  for  Persistent  Headache,  448. 

-  of  pre-Salicin  period,  Anticipatory 

of  .Serum  Therapeutics,  264. 
Block  Fibres  in  Heart,  28,  81 . 
Blocking     of     Coronary     Arteries, 

Results,  158-4,  UU. 

-  of  Heart,  sr.e  Heart-Block. 

-  of  Stimuli,  36  et  sqq. 
Blood,  as  "the  Life,"  12,  13. 

-  Action  through,  of  Hormones,  398 

-  Aeration  of,   Heart's   dependence 

on,  151,   284;    Defective    in 
Cardiac  Dyspnoea,  196-7. 

-  Chemical  Condition  of,  as  affecting 

Drug-action,  273,  278-9. 

-  Circulation  of,  ser  Circulation. 

-  Coagulability,     Diagnostic      use, 

Wright's  method,  145-6. 

-  Composition  of,  Drugs  Affecting, 

Indirect  Action  of,  on  Heart 
and  Vessels,  224. 

-  Condition  of,  Heart's  Health  de- 

pendent on,  on  what  itself 
dependent,  380,  881. 
-Defibrinated,  as  Nutrient  in  Arti- 
ficial Circulation,  273. 

-  -  Quickening  and  Slowing  of,  by 

Heat,  Oxygenation,  and  Bile 
Salts,  147. 

-  Diluted,  in  Experiments  on  Frog's 

Heart,  285. 


INDEX 


Blood  (cont.) 

-  Examination  of,  for  Micro-organ- 

isms in  Septic  Endocarditis 
and  Pericarditis,  878. 

I-  Flow  of  (see  also  Circulation),  in 
Aortic  Regurgitation,  218. 

-  -  Free,     through     Organs,     why 

Necessary,  397. 

-  -  Rate  of,  as  atfected  by  Viscosity, 

146-7. 

--in  Syncope,  Hunter's   Observa- 
tion on,  180-1. 

-  Irritant  qualities  of,  13. 

-  Liquid  Part  of.   Leakage  of,  into 

Tissues,  9. 

-  Local   distribution  of,  Variations 

in,  332. 

-  Pure  and  Poisoned,  Artificial  Cir- 

culation   of,    Effect    of,    on 
Vessels,  Apparatus  for,  271-2. 

-  Quality  and  Quantity,  as  affecting 

-  -  Cardiac  Nutritioi,,  151-2,  284. 

-  -  Cerebral  Activity,  425. 

-  Quantity  of,  in 

-  -  Body,  7. 

-  -  Cerebral  Arteries,  21. 

-  Viscosity  of,  in  relation  to  Arterial 

Pressure,  How  Ascertained, 
and  lessened,  146-7. 

-  Warm,  Effects  of  Drinking,  227. 

-  Withdrawal  of,  from 

—  Brain,  to  Relieve  Insomnia,  257. 
in  Syncope.  Faintness,  &c.,  180, 

219,  422. 

-  -  Limbs,  by  Actively  Functioning 

Brain,  180,  cf.  8. 

Blood-pressure,    see     also     Arterial 
Tension. 

-  Action,  or  Influence  on,  of 

-  -  Aconite,  328,  830. 

-  -  Adrenalin,  315. 

-  -  Alcohols,  438  4. 

-  -  Arterial  Contraction,  18. 

-  -  Depressor  Nerve,  65. 
--Digitalis,  M,(fig.) ib. 

-  -  Emotion,   Author's   Experience, 

112. 

-  -  Exercise,  110-12,  (fig.)  111. 

—  Extrinsic  Afferent  Nerves,  65. 

-  -  Food,  110. 

-  -  Nauheim    Treatment,    Author's 

personal    Observations    on, 
249,  (figs  )  246-7. 

-  -  Nitrite  of  Amyl,  Author's  per- 

sonal and  professional  Experi- 
ence with,  386-8,  (fig.)  337. 

-  -  Peripheral  and  Central  Action  of 

Drugs,  276. 


Blood-pressure,  Action,  or  Influence 
on,  of  (ecwt.) 

-  -  Pituitary  Gland  Secretion,  and 

Extract,  90,  819. 

-  -  Splanchnic  Area,  19. 
--Vagus,  17-18,  21. 

-  -  Vaso-dilators  (q.v.).  889. 

-  -  Vaso-motor  Centre  in  Medulla, 

17, 18,  20. 

-  Average,  in  Animals  and  Man,  S'6. 
-Backward,    in     Mitral     Disease, 

Double  effect  of,  S5\,(fig.)&52. 

-  Changes  in  (Oscillation),  Effect  of 

Pulse- rate  on,  11 6, (fig.  1)116. 

-  Definition  of,  15. 

-  Diastolic,  Measurement  of 

-  -  by  Finger  Pressure,  114. 

-  -  Instruments  for,  114-15. 

-  Drugs  lowering,  see  Vaso-dilators. 

-  Estimation   of,   Instruments   for. 

15-16,  95-6. 

-  Examination  of,  in  Man,  100  et  sqq. 

-  -  Bibliography  of,  120-2. 

-  in  Glomeruli  of  Kidney,  Secretion 

of  Urine  and,  Lud  wig's  and 
Bowman's  Theories  of,  846-7. 

-  High,  Aconite  in,  880. 

-  -  Atheromatous     Arteries     with, 

Risks  from,  202. 

-  -  Causes   of,  views  on,  of  Gull  & 

Sutton,  and  .'olinson,  recent 
Evidence  on,  200. 

-  -  Conditions  induced  by,and  induc- 

ing, see  Giddiness,  Insomnia, 
Senility,  &r. 

-  -  Effect  of,  on  Vagus,  17. 

-  -  Means  of   Relieving,  sec  Amyl, 

Nitrite  £  Bleeding. 

-  -  Venous  Pulsation  with,  222. 

-  Keeping  up,  in  Cerebral  Throm- 

bosis, Treatment  for,  456-7. 

-  Liver-Distention    in    relation    to. 

19,  20 

-  Low,  Affections  and  Conditions  in 

which  Present,181-3,  201, 423; 
Causes,  182. 

-  with  Lack  of  Carotid  Contractility, 

as  Cause  of  Insomnia,  864. 

-  Lowered  by  Depressor  Nerve.  65. 

-  Lowering  of,  Treatment  for,  in 

-  -  Aneurism,  454-5. 

—  Cerebral  Haemorrhage,  455-6. 

-  in  Man,  Age,  Sex,  and  Race  Varia- 

tion in,  109-10. 

-  -  in  Capillaries,  Measurement  of, 

119-20. 

-  -  Diastolic,  Cardiac  Sounds  associ- 

ated with,  113. 


472 


INDEX 


Blood-pressure,    in    Man,    Diaatolic 
(cont.) 

Defined,  11 2-8. 

Measurement  of,  113. 

-  -  on  What  Dependent,  118. 

-  -  Measurement   of,    100 ;    Instru- 

ments for  (set  Kymograph, 
Manometer,  Oscillometer, 
Sphygmobolometer,  Tono- 
meter, &c.\  described,  101 
et  sgq. 

-  -  in  Veins,  Methods  of,  119. 
--Systolic  and  Diastolic,  relation 

between,  i.e.  Pulse-pressure 
(q.v.),  115  et  sqq. ;  (fig.  8)  116, 
117, 118. 

-  Reduction  of,  in 

—  Local  Inflammations  by 
Aconite,  253. 

Heat  and  Cold,  258-4. 

-  Regulation  of,  16, 17, 146. 

-  -  Nervous  Control  and  Relief  of, 

17, 18,  20,  21,  65,  94. 

-  -  Part  in,  of  Ductless  Glands,  89-90. 

-  in    Renal   Disease,    Variation    in, 

Causes,  91,  92. 

-  Rise  of,  Action  on  Pulse-rate,  162. 

-  -  in  Angina  Pectoris,  188-9. 

—  Caused  by 

Caffeine,  318. 

Camphor,  816. 

Coughing,  228-9. 

Digitalis,  802,  303,  (fig.)  302. 

Discoveries  on,  of  Blake  and 

Traube,  295-6. 
Nature     of,     according     to 

Traube  and  von  Bezold,  299; 

according     to    Author    and 

Meyer,  299-801 ;  Author  and 

Tunnicliffe,  301. 
Drugs,   those   most  Effective, 

315,     323;      Effect     of,    on 

Coronary  Arteries,  343. 

Nicotine,  323. 

Smelling  Salts,  422. 

Suprarenal  Extract,  828. 

-  -  Senile,  201-2. 

-  -  Sudden,  Various  Reasons,  Extra 

Systole  Induced  by,  171-2. 

-  Schema  of,  94-5,  (fig.)  95. 

-  Systolic,  on  What  Dependent,  113. 

-  Variations  in,  as  affeeting  Second 

Heart  Sound,  210-11. 

-  Within  Heart  or  Aorta,  Lowered  by 

Depressor  Nerve,  65. 
Blood-serum,      Normal,     Adrenalin 
present  in,  Effects  of,  How 
Demonstrated,  289. 


Blood-supply,  How  Regulated,  7-9. 

-  Imperfect,  Symptoms,  402,  407. 

-  Importance  of  Quality  and  Quan- 

tity, 150-1. 

Blood-vessels,  see  Arteries,  Arterioles, 
Capillaries,  Vasa  Vasorum 
Veins,  <Cc. ,  see  also  Abdominal, 
Cerebral,  <tc. 

-  Action  on,  of 

-  -  Adrenalin,  276,  315,  323. 

-  -  Alcohol,  483. 

-  -  Caffeine,  276. 

-  -  Camphor,  816. 

--Digitalis,  295,  302-8,  312-8,  488, 
(fig.)  802. 

-  -  Drugs,  382  et  sqq. 

those  which  work   Indirectly, 

284. 

-  -  Erythrophlceum,  812. 

-  Alteration    in,   Senile    Decay    as 

Caused  by,  204. 

-  Atheromatous  changes  in,  Cause 

and   Result,  200,    in    Senile 
Decay,  204. 

-  Contraction  of,  by 

-  -  Adrenalin,     how    Counteracted, 

276,  315,  328. 

--Digitalis,  q.v.,  &c.,  Risks  from, 
812-3. 

-  Dilatation  of,  Aim  of  Treatment  in 

Angina  Pectoris,  441. 

-  -  Drugs    Inducing,    see    Alcohol, 

Amyl  Nitrate. 

-  -  by    Heat     and     Cold     Locally 

applied,  92,  258  et  sqq.,  432; 
Author's  own  experience,  254. 

-  -  Hot  Baths,  Palpitation  due  to, 

415. 

-  -  by  Rubbing  and  Cold  Water  more 

Lasting  than  from  Immersion 
of  Feet  in  Hot  Water,  427. 

-  -  Sudden,  in  Muscles,  and  Syncope, 

181. 

-  Diseases  of,  see  Atheroma,  Sclerosis, 

-  -  Age-Incidence   of   Mortality   in, 

202. 

-  -  Insomnia  in,  Causes,  Theories, 

363-4. 
Drugs  to  Relieve,  364-5. 

-  Exudation  of  Fluid  from,  (Edema 

due  to,  223,  224,  310. 

-  Fibrillation  in  relation  to,  153. 

-  and  Heart,  see  Heart  and  Vessels. 

-  Lack  of  Tone   in,  Effect  of,   and 

Treatment,  432;  Action  on, 
of  Digitalis,  432. 

-  Nerves  of,  Opposing  Action  of,  85. 


INDEX 


473 


Blood-vessels  (cont.) 

-  Nutrition  of,  Effect  on,  of  Heart 

weakness,  157-8. 

-  Physiology  of,  84  et  sqq. 

-  -  Bibliography  of,  96-9. 

-  Senile   Conditions  of,   Treatment, 

452  et  sqq. 

-  Size   of,    largely   Conditioned    by 

Amount  of  Oxygen  in  Blood, 
333. 

-  -  Means  of  Measuring,  118-9. 

-  Stimulation  of 

-  -  from  Within,  89. 

-  -  from  Without,  8S-9.  (fig.)  85. 

-  Local,  87. 

Blow  on  Epigastrium,  Shock  from, 
Goltz's  Experiment,  178,  (fig.) 
ib. 

Blushing,  Morbid,. Treatment,  449-50. 

Body,  Circulation  through  (q.v.), 
Object  of,  How  Initiated,  77. 

-  Condition  of,   as   Affecting   Drug 

Action,  273,  278-9. 

-  Growth     and    Development     of, 

Action  on,  of  Thvroid,  and 
Pituitary  Glands,  396-7. 

-  Positions  of,  in  Nauheim  Exercises, 

245,  248. 

-  Sleep  of,  4. 

-  Stretching  of,  Action   during,  of 

the     Limb-Fasciae    on    the 
Venous  Circulation,  11-12. 

-  Temperature  of,  as  Affecting  Drug- 

action,  273,  281-2. 

-  -  in  Fever,  Double  Effect  on  Pulse, 

94. 

-  -  Normal  Equilibrium  of,  93-4. 
Boric  Acid  Solution,  and  Ointment, 

for  Pruritus  anl,  429,  430. 
Bottle   for    Medicating   Oxygen,    as 

made  for  Author,  241-3,  (figs.) 

242,  248. 

Bowditch's  Law,  £6. 
Bowels,    see    alto     Evacuations,    & 

Intestines. 

-  Effect  on,  of  Emotion,  158. 

-  Emptying  of,  Difficult  in  Recum- 

bency, 236. 

-  Laxative  Action  on,  of  Green  Vege- 

tables, 379. 

-  Regular  Action  of,  Why  Desirable, 

394,  443. 

-  Treatment  to  Ensure,  in 

-  -  Angina  Pectoris,  443. 

-  -  Cerebral  Thrombosis,  445-6. 

-  -  Prevention  of  Insomnia,  431. 

-  -  Senile    Conditions    of    Blood- 

vessels, 453. 


Brachial  Artery,  Auscultation  of,  to 
Ascertain  Diastolic  Pressure, 
Korotkow's  Method,  113. 

Bradycardia.orBrachycardia.Causes, 
Incidence,  Indications, Treat- 
ment, 165  et  sqq.,  420-1,  (figs.) 
166, 169. 

-  Congenital,  best  left  alone,  420. 

-  Irregular,  Cause  (apparent),  170. 

-  Paroxysmal,     Induced     by    Tea, 

Coffee,    and    Tobacco,    168, 
(fig.)  169. 

Brain,  fee  also  Cerebral,  Medulla 
Oblongata. 

-  Ansemia  of,  in  Syncope,  180. 

-  Arteries  of,  Blood  Content  of,  21. 

-  -  Distribution  of  (fig.),  205. 

-  Circulation  in,  see  Cerebral  Circu- 

lation. 

-  Conditions  of ,  Producing  Giddiness 

in  Young  and  Elderly  People, 
201 

-  Defect  of  Blood-supply  to,  Symp- 

toms   (Faintness,    Syncope, 
&c.),  180,  219,  422. 

-  Frontal  Lobe  of,  Disordered  Circu- 

lation to,  Mental  Disturbance 
from,  205-6. 

-  Pressure  in,  Causing  Bradycardia, 

166. 

—  Increased,    Various    Modes    of, 

420. 

-  Rupture  in,  of  Blood-vessel,  Re- 

sults, 204. 

—  Differential   Diagnosis   of,   from 

Thrombosis,  145-6. 

-  Selective  Action  on,  of  Alcohol,  and 

the  Aliphatic  Series,  275. 

-  Sleep  of,  4. 

-  Stimulated   by    Tobacco-smoking, 

326 

-  and  Vagi, Experiment  on, of  Franck, 

17  w. 

-  as  Vascular  Area,  19. 

-  Withdrawal    from,    of   Blood,    to 

Relieve  Insomnia,  255. 
Brain-cells,  Amoeboid   Dendrons  of, 
Powers  of,  and  Susceptibility 
to  Stimuli,  425. 

-  Hypnotics  Acting  on,  433. 

-  Senile,  Action  on,  of  Macrophags, 

Metchnikoffs  Views,    203-4, 
(fig.)  203. 

Brandy,  Action  of,  in  Relief  of  Faint- 
ness,  422. 

-  Dosage  with,  in  Rheumatic  Fever, 

373-4. 

-  with  Milk  as  Hypnotic,  433. 

2    I 


474 


INDEX 


Bread,  Saltless,  but  with  Sugar,  in 
Mitral  Disease,  258. 

Bread-crumb  Poultices,  255. 

Breatb,  Shortness  of  (see  also  Cardiac 
Dyspnoea),  in  Aortic  Disease, 
403. 

-  -  Treatment  called  for  in,  409. 
Breathing,  Difficulty  of,  in  Ascites 

from      Abdominal     Venous 
Engorgement,  225. 
--in    Recumbent    Position,    How 
Caused,  234. 

-  Rapid,  to  Distress-point  in  Cardiac 

Asthma,  444-5. 

Breathlessness,  see  also  Cardiac 
Dyspnoea. 

-  Associated     with     Mitral     Affec- 

tions, 250-1,  470. 

-  Cardiac  Causes  of,  182. 

Bright's  Disease,  Bradycardia  from, 
166. 

-  -  Digitalis   in,   need    of    Caution 

with,  313. 

--Effect  on  Arteries,  126,  (fig.) 
118. 

Brodie,  Sir  Benjamin,  cited  on  Claudi- 
cation  in  relation  to  Angina 
Pectoris,  194-6. 

Bromide  of  Potassium,  in  Brady- 
cardia, 420. 

-  -  in  Headache  mixture,  449. 

-  of  Sodium  in 

—  Graves's  Disease,  416. 

—  Insomnia  (with  Digitalis),  432. 
--  Palpitation,  413. 

-  -  Raynaud's  Disease,  450. 
Bromides,  Action  of,  on  Reflex  Stimu- 
lation of  Nerves,  438. 

-  with  Digitalis,  in  Insomnia  from 

Lack   of    Tone   in   Vessels, 
432. 

-  for  Flushes  of  Heat  and  Blushing, 

449. 

-  for  Palpitation,  413. 

-  in  Paroxysmal  Tachycardia,  419. 

-  for  Quieting  Patients  with  Graves's 

Disease,  416. 

-  Taste  of,  Masking  of,  413. 
Bronchi,  Reflex  Stimulation  from,  of 

Vagus,  Effects  on  Heart,  73. 

Bronchioles,  Muscular  fibre  of,  in 
Cardiac  Dyspnoea,  197. 

Bronchitis,  Chronic,  Cardiac  Weak- 
ness from,  228. 

-  Suffocative,  Wet  Cupping  in,  258. 

-  Terebinthine  preparations  used  in, 

with  Bottle  for  giving  Medi- 
cated Oxygen,  243. 


Bronzing  of  Skin  in  Addison'.s  Dis- 
ease, Influence  on,  of  Disease 
of  .Suprarenal,  90. 

Brown  Atrophy,  common  in  Chronic 
Valvular  Disease,  and  in  Old 
people,  153. 

Bruit,  or  Murmur,  tee  Cardiac  Mur- 
mur. 

Bufotalin,  Action  of,  on  Outside 
and  on  Inside  of  Frog's 
Ventricle,  270. 

Bulb  Sphygmomanometers,  102-3, 
J04-7. 

Bundle  of  Stanley  Kent  and  His,  57. 

-  Clamping  of,  Heart-block  due  to,59. 

-  Lesion   of,    with  Heart-block    as 

Cause  of  Stokes- Adams  Syn- 
drome,  168. 

Burdon-Sanderson,  Sir  John,  Record- 
ing Manometer  of,  15. 

Burns,  Allen,  cited  on  Claudication 
and  Angina  Pectoris,  194. 

Burns  from  Uncovered  Hot  Water- 
bags,  427. 

Bursting  of  Cerebral  Blood-vessel, 
and  Thrombosis,  differential 
Diagnosis  of,  by  Coagulability 
of  the  Blood,  145-6. 

-  Results  of  the  former,  204. 
Butyl   Chloral,    of    little    Hypnotic 

use,  434. 

CACTUS  grand  i  flora,  811. 
Caffeine,  Action  of,  on 

-  -  Coronary  Arteries,  344 

-  -  as  Diuretic,  348. 

-  -  Embryonic     Heart,     Pickering, 

Author,  and  Cash  on,  298. 

-  -  Frog's  Muscles,  Different  results 

obtained  by  Different  Ob- 
servers, Reason  for,  2S4. 

-  -  Heart,  364,  488 ;  in  Large  and 

in  Small  Doses,  288;  Nutrient 
as  well  as  Stimulant,  155-6. 

-  -  Kidney    Circulation,    349,    and 

Secreting  Structures,  SOS. 

-  -  as  Nerve-stimulant,  317-8. 

-  -par  excellence,  as  Cause  of  Tonic 

Contraction,  298. 

-  -  Peripheral  and  Central,  27C. 

-  -  Probable  Process,  317-8. 

-  -  Secreting  Structures,  808. 

-  -  Vaso-motor  area,  335. 

-  Insomnia  from,  364. 

-  with  Digitalis  in  Aortic  Regurgi- 

tation,  406. 

Cajuput,  Oil  (and  Spirit),  as  Car- 
minative, 860,  861. 


INDEX 


475 


Calcification  or  Ossification  of 

—  Aorta,  Nature  of  Second  Sound 

with,  211. 

-  -  Arteries,    Frequent    in    Angina 

Pectoris,  191 ;    in    the  Old, 
194;  Prognosis,  156. 
Calcium  and  its  Salts,  effects  of,  on 
Transudation,  252-8. 

-  Chloride,  in  Graves's  Disease,  416. 

-  in  Saline  solution,  Effects  on  Heart, 

285-6. 

-  in  Solution  with  Sodium  Chloride 

and  Potassium,  Precaution 
re,  71. 

-Salts,  Normal,  Withdrawal  of, 
Effects  on  Action  of  Adre- 
nalin on  the  Sympathetic 
System,  279. 

Calomel  (tee  also  Mercury),  in  Cerebral 
Haemorrhage,  455-6. 

-  as  Diuretic,  850-1. 

-  for  Elimination   in  Acute    Rheu- 

matism, 375. 

-  as  Intestinal  Disinfectant,  859. 

-  Ointment  of,  for  Pruritus  ani,  430. 
Camphor,  Action  of,  on,  and  as 

—  Carminative,  860. 

-  -  Heart,  Stimulant,  310,  438. 
in  Removal  of  Fibrillation,  316  ; 

with  Adjuncts,  63. 

-  -Splanchnic and Vaso-motor Areas, 

385. 
Canadian  Hemp  (Apocynum  Canna- 

bintim'),  311. 
Canadians,    Blood-pressure   maxima 

in,  110. 
Cancer,    Reflex    Stimulation    in,    of 

Vagus,     Bradycardia    from, 

167. 
Cane  Sugar,  as  used  in  Treatment  of 

Failing  Heart,  by  Goulston 

and  Carter,  287. 
Cannula,   for   Tapping   for  Ascites, 

261  ,(fig.)  262. 
Capillary    Electrometer,  use  of,  by 

Marey  and  others,  139. 
Capillary(ies),  Blood  of,   Nutriment 

supplied  by,  to  Lymph,  18. 

-  Blood-pressure    in,    Measurement 

of,  119-20. 

-  Circulation  in,  9. 

-  Contraction  of,  by 

-  -  Cold,  and  High  Tension  in  the 

Elderly,  182,  (jig.)  ib. 

-  -  Digitalis,  Blake's  conclusions  on, 

295 

-  -  Ductless  Glands,  89. 

-  -  Heat  and  Cold,  94. 


Capillary(ies),  Contraction  of  (cont  .) 
—  in  relation  to  Diastolic  Pressure, 

113,  116-8,  (fig.)  116. 
-  Dilated,  Effect  on  Sphygmograms, 


-  Pulmonary,  Collapse  of,  in  Mitral 

Obstruction,  222. 

-  -  Contraction  of,  from  Heat  and 

Cold,  94. 

-  Size,    in   relation    to   Outflow   of 

Arterial  Blood,  146 

-  Structure,  84. 

-  Vaso-dilators  affecting,  339. 

Car  bamate  of  Ethyl,  as  Hypnotic,  435. 
Carbohydrates,  Digestion  of,  386,  393. 

-  Fermentation    of    Gases    derived 

from,  355,  358,  377. 
Carbolic  Acid,  as  Gastric  Antiseptic, 
356. 

-  -  Ointment  of,  for 

---  Eruption-Pustules,    from     Io- 

dides, 342. 

---  Pruritus  ani,  430. 
Carbonate  of  Ammonium,  to  Abort 

attacks     of     Stokes-Adams 

Disease,  421. 

-  of  Magnesia  for  Chronic  Urticaria, 

451. 
Carbonates  and  Bicarbonates  of  Soda, 

Action  of,  on  Stomach  Wall, 

387. 
Carbonic  Acid,  Stomach  Peristalsis 

stimulated  by,  888. 
Carbonic  Acid  Gas  (CO-^)  in  Blood, 

Accumulation    of,    Causing 

Increased  Viscosity,  147,  151. 

-  One  of  the  Chief  Intestinal  Gases, 

355,  357,  377. 

-  Removal  of,  from  Tissues,  13. 
Cardamoms,  Compound  Tincture  of, 

as  Carminative,  361,  362. 
Cardiac,  see  also  Heart. 

-  Action,  as  affected  by  Emotions, 

158-60. 

—  Excessive,  Crushed  Ice  Applica- 
tion for,  263. 

-  -  Irregularity  of,  Why  (probably) 

Chiefly  Associated  with  Mitral 
Constriction,  222. 

-  Area,  Leeches  over,  in  Relief  of 

Pericarditis,  258. 

-  Asthma,  see  under  Asthma. 

-  Beat  or  Pulsation  (see  also  Heart 

beat),  Origin  of,  77-8. 

-  -  Slowing  of,  by  Vagus,  64. 

-  Contractions,  Feeble,  Regurgitation 

from,    even    with    Healthy 
Valves,  75,  (fig.)  ib. 


476 


INDEX 


Cardiac  Contractions  (cent.) 

-  -  Increased  Power  from  Pituitrin, 

319. 

-  Cycle,  Duration  of,  4. 

-  Debility  (see  also  Heart,  Feebleness) 

and  Dilatation  in,  Pituitrin 
in,  How  Best  Given,  820. 

-  Depressants,  284,  323  et  sqq. 

-  -  Aconite  Typical,  328. 

-  Dilatation,  Causes,  217. 

-  -  Differential  Diagnosis   of,    from 

Pericardial  Effusion,  377. 

-  -  Pituitrin  in,  320. 

-  -  X-ray  Examination  for,  188 

-  Discomfort,  Altitude  in  Relation 

to,  250 ;  Symptomatic,  219. 

-  Diseases  (see  also  under  Names), 

Drugs  Useful  in,   on    Myo- 
genic,   and    on    Neurogeuic 
Theories,  47. 
—  Acute,  Chronic,  see  under  Heart. 

-  -  Treatment  of,  Methods  of,   282 

et  sqq. 

Bibliography,  264  et  gqq. 

Best  (q.v.),  Extreme  Value  of, 

282  et  sqq. 
Uses  of,  232. 

-  Dyspncea,  Causes,  Nature,  Treat- 

ment, 182, 196-7,  222-3,  260-1, 
403,  409,  (Jig.)  75. 

-  Efficiency,  from  Stimulation  of  Ac- 

celerator and  Vagus  Nerves, 
72. 

-  Failure,  Death  fiom,  from  High 

Tension,  452. 

-  -  Senile,  How  to  Avert,  454. 

-  Hypertrophy,   of    High    Tension, 

Good  and  Bad  Sides  of,  452 

-  -  X-ray  Examination  for,  138. 

-  Irregularity,       from       Excessive 

Smoking,  and  from  "Pigtail  " 
more  than  from  Better  Class 
Tobaccos,  327;  Effects  with 
both  sorts,  827,  828. 

-  Movements,  Electric  Changes  Ac- 

companying, Instruments  for 
Noting,  Uses  and  Users  of, 
189-45. 

-  Murmurs  (see  also  Heart  Sounds), 

Nature,  Causes  and  Indica- 
tions, 213  et  sqq. 

-  -  Aortic,  218. 

-  -  Functional,  215-7,  (Jig.)  75. 

-  -  in  Health,  218. 

-  -  Mitral,  75. 

-  -  Organic,  214-5. 

-  -  Pulmonary,  216-7. 

-  -  Systolic,  214,  216,  217,  218. 


Cardiac  Murmurs  (cont.) 

-  -  Timing  of,  188. 

-  -  Transient,  75,  217-8. 

-  Muscle,  Nature  of,  52,  (fig.)  61. 

-  -  Action  on,  of 

Aconite,  828-9. 

Bile  Acids,  168. 

Catteine,  in  Large  Doses,  288. 

Digitalis  (q.v.),  807. 

Diphtheritic  Toxin,  162, 160. 

-  -  Diet  to  Strengthen,  in  Oertel's 

Treatment,  250. 

-  -  Drugs  Acting   on   Value  of,  in 

Cardiac  Disease,  47. 

-  -  Fibrillation  of,  Causes,  55,  Re- 

sults, 63. 

-  -  Potassium  given  off  by,  more, 

when  Vagus  in  Action,  71. 

-  -  Restoration  of,  Vagus  Action  in, 

Gaskell  cited  on,  70-1. 

-  -  Weakness  of,  Bradycardia  from, 

168;  When  Observed,  Treat- 
ment, 420-1. 

Causes,  152 ;  Effects  on  First 

Heart  Sound,  212. 

-  Nerves,  Are   they  Useless  ?  82-3, 

(fig.)  69, 

-  -  Effect   on,    of    Strong    Electric 

Currents,  55 

-  -  Intrinsic,  Action  on,  of  Digitalis, 

307. 

-  -  Opposing  Action  of,  32,  84-5. 

-  -  and  Regulation  of  Pulse-rate,  161. 

-  Nutrients,  155-6,  284  et  sqq. 

-  Nutrition,  Effect  on,  of  Cardiac 

Feebleness,  154. 

-  Pain  (see  Angina,  <&c.),  in  Aortic 

Disease,  407. 

-  -  Causes  and  Treatment,  257,  827, 

440-1. 

-  Patients,    Exercise,    Games,    and 

Sports  for,  Rules  for,  251-2. 

-  Plexuses,  63. 

-  -  Anterior  (fig.),  54. 

-  -  Branches  of  Vagus  going  to,  67, 

and  in,  Irritation  of,  as  Cause 
of  Bradycardia,  167. 

-  -  Nerves  to,  from  Cervical  Ganglia, 

64. 

-  Poisons,  see  Poisons,  Cardiac. 

-  Pulsations,  Effect  on,  of  Stimula- 

tion of  Vagus  Trunk  and 
Centre,  by  Electricity  and  by 
Digitalis,  61. 

-  Region,  Pain  in,  827. 
Chief  Seats  of,  187-8. 

Hot  Air  Bath  in  Relief  of,  257. 

-  Remedies,  Action  of,  266  et  sqq. 


INDEX 


477 


Cardiac  (eont.) 

-  Rhythm,  Mitral  Disease  as  Affect- 

ing, 220  et  sqq. 

-  -  Nervous  Control  of,  172. 

-  -  Origin  of,  27. 

Myogenic      and       Neurogenic 

Theories  on,  27 

-  -  Persistence  of,  after  Excision  of 

Heart,  27. 

-  -  Perturbations  of,  211,  220,  (fig.) 

220. 

-  Sounds  (see  also  Heart  Sounds  and 

Murmurs)  Associated    with 
Diastolic  Pressure,  113. 

-  Stimulants,  284. 

-  -  Caffeine  and  other  Purin  Bodies 

as,  317-9. 

-  -  Camphor,  316. 

-  -  Cardiac  Tonics  Acting  as,  294. 

—  Lime  as,  285. 

-  -  Purin  Bodies,  287-8. 

-  -  Strychnine,  47,  316-7. 

-  Strain,   Dilatation   from,  Cardiac 

Murmurs  in,  217. 

-  Symptoms,   Causes,  according  to 

Oertel,  250. 

-  Tonics,  284,  288  et  sqq. 

-  -  Action  of,  294  et  sqq. 

-  -  Bibliography  on,  319-22. 
Difference     between    that     of 

Digitalis  and  Others,  312. 
Drawbacks  to  that  of  Digitalis, 

&c.,  312-3. 
Removal  of,  by  Combination, 

313. 
on  Embryonic  Heart,  Mode  of, 

Pickering  on,  297-8. 

-  -  Nutritive,  155-6. 

in  relation  to  Oxidation,  297  et 

sqq. 

—  Pituitary  Extract  as,  319. 

-  -  Stimulant  Effects  of,  294. 

-  Treatment,  Use  of,  232. 

-  Uneasiness,  of  what  a  Symptom, 

219. 

-  and  Vascular  Remedies,  Action  of, 

266  et  sqq. 

-  -  Bibliography  on,  290-3. 

—  Classification  of,  284. 

-  Walls,    Permanent    Weakness   of, 

Cause  of  Bradycardia,  167. 

-  Weakness  (see  also  Debility,  above), 

Dilatation  from,  217. 

-  -  Extreme,    Gallop    Rhythm    In- 

dicative of,  212. 

-  -  Mitral  Murmurs  in,  Temporary, 

How  Caused,  75. 

-  -  Sugar  Treatment  of,  253.  287. 


Cardiogram,  Normal,  Deflections  in, 
141-2;  How  Obtained,  123-6. 

-  of  Aorta  Pulse  (fig.),  124. 

-  -  Apex-beat,  126. 

-  -  Carotid  Pulse,  127. 

-  -  Ventricular  Systole  (fig.),  124.    . 
Cardiographs,  Marey's,  Principle  and 

Uses,  123-6. 

Carminatives,  and  Adjuncts,  Nature 
and  Action  of,  357,  360-2, 
374. 

-  in  Relief  of  Angina  Pectoris,  189, 

442 ;    of  Pulse  Irregularity, 
438-9. 

Carotid  Arteries,  as  affected  by  Aortic 
Regurgitation,  404. 

-  -  Capacity,  21. 

-  -  Condition  in  Migraine,  184,  (fig.) 

ib. ',  Effect  of  Pressure  on, 
185. 

—  Conditions  of,  Unfavourable  to 
Sleep,  200,  364,  432. 

-  -  Contractile  Power  of,Brain  Circu- 

lation Controlled  by,  363. 

-  -  Pulse  in,  Best  for  Timing  Cardiac 

Murmurs,  138. 

Cardiograms  of,  how  made,  127. 

Comparison  of,  with  Auricular 

Systole,  137,  (fig.)ib. 
Sphygmogramsof,  129,  (fig.)  137. 

-  -  Sclerosis  of,  364. 

-  -  Systolic  Rise  in,  129,  (fig.)  il>. 
--Throbbing  in,  177. 

Carui,  Oil,  and  Water  of,  as  Carmina- 
tives, 360. 

Caryophyllum, Oil  of,  as  Carminative, 
360. 

Casca,  or  Sassy  Bark  (Erythrophlmvm 
guineense),  congener  of  Digi- 
talis, 311,  Action  of,  on 
Kidneys,  304,  307. 

Cascara,  as  Eliminant,  375 ;  in 
Senile  Conditions  of  Blood- 
vessels, 453. 

Castor  Oil,  in  Cerebral  Haemorrhage, 
456. 

Catarrh,  Gastric,  and  Dyspepsia  from 
Post-nasal  Catarrh,  390-1. 

-  of  Mucous  Membrane,  Action  of, 

on  Pylorus,  300. 

-  Post-nasal,  Headache  from,  447. 

-  -  Gastric  Catarrh  and  Dyspepsia 

from,  390-1. 
Cautery,  in  relief  of  Cardiac  Pain, 

Locale  for,  441. 
Cell  from  Brain  of  Woman  aged  100 

years,    being    Devoured    by 

Macrophags  (fig.),  203. 


478 


INDEX 


Cell  (cont.) 

-  Kin-lick's  Schema  of  a,  in  relation 

to  Inurement  to  Poisons, 
280. 

Cells,  Connective   Protoplasmic,   of 
Heart,  53. 

-  Contractile,  Capillaries  Composed 

of,  84. 

-  taken  from  a  Heart  in  Fibrillation 

(tig.),  51. 

Central  Action  of  Drugs,  278,  276. 
Centripetal  Nerves,  Reflex  Irritation 

of,  Vagus  from,  73. 
Cerebral    Abscess,    Trephining    for, 

Effect  on  Pulse-rate,  162. 

-  Activity. Stimuli  exciting,  Sources, 

428  ;  Part  played  in,  by  Den- 
drons  of  Brain-cells,  425. 

-  Apoplexy   (see    also    Blood-vessel 

Rupture,  below),  How  to 
Avert,  454.1 

-  Arteries,  Action  on,  and  on  other 

Blood-vessels,  of  Adrenalin, 
21,  384. 

-  -  Distribution  of,  compared  with 

that  of  Cerebral  Functions, 
206  &  fig. 

-  Blood-vessel(s),    Contraction    and 

Dilation  of,  Independent,  dis- 
cussed, 20-21. 

-  -  Pressure,  in  relation  to  Menstrual 

Headache,  449. 

-  -  Quiescence  in  Sleep,  Natural,  and 

Induced,  363. 

-  -  Rupture  of,  Results,  Treatment, 

202,  452,  455. 

-  -  Stoppage    of,    Various    Causes, 

Differential  Diagnosis  by 
means  of  Coagulability  of  the 
Blood,  145-6. 

-  Circulation,  21. 

-  -  Failure  of,  Cause  of  Faintness, 

422,  and  Giddiness,  428. 

-  -  Insomnia  in  relation  to,  200,  368, 

425. 

-  -  Position,    to    Increase,    and    to 

Avert  Faintness,  421. 
—  Sleep  and  Waking,  in  relation  to, 
368. 

-  Cortex,  and  Distribution  of  Func- 

tion^.), 206. 

-  Functions,  Distribution  of,    com- 

pared with  that  of  Cerebral 
Arteries.  206,  (fig.)  (b. 

-  Haemorrhage,  Causes,  and  Results, 

145 ;  Safety-valve  action  of 
Left  Ventricle  Averting,  78  ; 
Treatment,  455-6. 


Cerebral  (cont.) 

-  Motor  Centres,  Functions  of,  How 

Abolished,  186. 

-  Tension,  Lessened  in  Sleep,  200. 

-  Thrombosis,  Treatment,  456-7. 

-  Tumour,  Bradycardia  from,  166. 
Cerebro-spinal    Nerves,    Class     and 

Part  affected  by  Small  Doses 

of  Atropine,  274-6. 
Cerebrum,     Susceptibility     of,     to 

Stimuli,  425. 
Cervical  Cord,  Disease  or  Injury  of, 

Bradycardia  in,  167. 

-  Ganglia,     Nerves    from,    to    the 

Central  Plexus,  64. 

Chalones,  Nature  and  Functions,  893. 

Charcoal,  Vegetable,  as  Gastric  Anti- 
septic, 356. 

Cheese,  Value  of,  in  High  Tension, 
Why  Considered  Indigestible, 
389. 

Chemical  Action,  in  relation  to  Vagus 
Action,  and  to  Transmission 
of  Stimuli  through  A-V 
bundle,  286. 

-  Changes,  in  Stomach,  during  Secre- 

tion, 891-2,  (fig.)  392. 

-  Condition  of   Blood,  as   affecting 

Drug-action,  273,  278-9. 

-  Stimulation,  Action  of,  on  Pylorus, 

388-9. 

Chest,  Constriction  in,  on  passing 
from  Warm  to  Cold  Air,  94. 

-  Oppression  felt  in,  in  Angina,  188, 

in  Grief,  Author's  Experi- 
ence, &c.,  186-7  <&n.,  in  Mi- 
graine, 185. 

Cheat-wall,  Ape<c  Striking  against, 
Cause  of  Palpitation,  76-7, 
176-7,  218,  226,  (fig.)  220. 

Chewing  Tobacco,  Absorption  by,  of 
Nicotine,  325. 

Chicken,  Breast,  in  Diet  of  Conval- 
escents from  Acute  Heart 
Disease,  379. 

Chilblains,  Cause,  198;  Treatment  ,450. 

Childbirth,  Bradycardia  and  Slow 
Pulse  after,  167. 

China  Tea,  for  Cardiac  Patients,  380. 

Chloral,  Action  of,  on  Heart,  434 

-  Alkaline CourseAdvisable with, 484. 

-  and    Compounds    as    Hypnotics, 

484-5. 

-  Overdose  of,  Why  Sometimes  Fatal, 

Treatment,  434. 
Chloral-poisoned  Heart,  Effect  on,  of 

Camphor,  316. 
Chloralamid,  as  Hypnotic,  434-5. 


INDEX 


479 


Chloralose,  as  Hypnotic,  435. 
Chloride    of    Calcium,    in    Graves's 
Disease,  416. 

-  of   Sodium,  in    Graves's  Disease, 

415. 

-  -  in  Mucous  Membrane,  391. 
Chloride-free  Diet,  in  Cardiac   Dis- 
eases, 252-3. 

Chloroform,  Effect  of,  on  Medusa,  36. 

-  Fatty  Degeneration  of  the  Heart 

Induced  by,  151. 

-  Fibrillation  from  Rapid  Applica- 

tion of,  63. 

-  to  Believe  Angina  pain,  442. 

-  in  Severe  Insomnia  of  Heart  .Dis- 

ease, 436. 

-  Stoppage    of  Dogs'   and  Rabbits' 

Hearts  from  Inhaling,  73. 

-  Spirit  and  Water  of,  as  Carmina- 

tive, 360,  with  Cardamoms, 
same  use,  362,  to  Mask  Taste 
of  Iodides,  841. 

Chlorosis,  Bradycardia  in,  167. 

Chocolate,  as  Nerve-Stimulant,  318. 

Cholera,  Blood-pressure  Low  in,  181. 

-  Toxins  of.  Local  Irritation  from, 

304. 

Chorda  Tympani,  Action  on,  of 
Atropine,  274. 

-  Irritation  of,  Effect  on  Submaxil- 

lary  gland,  parallel  to,  181. 
Christmas  Tose^helleborusniger),  311. 
Chronic   Heart   Disease,    see   under 

Heart  Disease. 
Chronotrope,  56. 
Chyme,  Acid,  Action  of,  on  Duodenal 

Mucous  Membrane,  393. 

-  Acidity  of,  Absorbed  on  Passage 

into  Intestine,  391-2. 

Cigar-smoking,  Difference  between, 
and  other  Forms  of  Smoking, 
325-6 

Cigarette-smoking,  325,  Why  Injuri- 
ous, 826. 

Cinnamon,  Oil,  Spirit,  and  Water  of, 
as  Carminatives,  SCO. 

Circulation,  see  also  Artificial,  Cardiac 
Rhythm,  Cerebral,  Entero- 
hepatic,  Pulmonary,  Renal, 
tC  Venous. 

-  Action  on,  of 

-  -  Aconite  in  Small  Doses,  329. 

-  -  Digitalis,  308. 

-  -  Drugs,  266-7. 

-  -  Emotion,  136-7,  159-60. 

-  -  Excessive  Smoking,  327. 
-  Heat  and  Cold,  92  et  sqq. 

-  -  Massage  and  Rest,  237-8. 


Circulation  (cant.) 

-  Arrest  of,  by  Coagulation  of  the 

Blood,  Differential  Diagnosis 
of,  145. 

-  Course  of,  in  and  through 

-  -  Aorta,  26. 

-  -  Arteries,  7,  8,  9,  26. 

-  -  Arterioles,  8,  9. 
—  Capillaries,  9. 

-  -  Veins,  9. 

-  Cranial,  and  Headache  of  Menstrual 

Period,  449. 

-  Depressed,  Action  on,  of  Pituitrin, 

319. 

-  Diagram  of  (fig.),  1C. 

-  Disordered,  Symptoms,  175  et  sqq. 

-  -  Vicious  Circle  of,  229-80. 

-  Disturbed  by  Lying  on  Back  at 

Night,  412. 

-  during  Syncope,  Hunter's  Observa- 

tion, 180-1. 

-  Examination  of,  123  et  sqq. 

-  -  Bibliography  of,  148-9. 

-  -  Instruments  for,  see  Cardiographs, 

Coagulometers,  Galvanomet- 
ers, Sphygmographs,  &c. 
-Factors  in,  Chief,  3-6,  7-8;   Sub- 
sidiary, 9-12. 

-  General  Physiology  of,  1  et  sqq. 

-  -  Bibliography,  22-4. 

-  -  Diagram  of  (fig-),  16;  see  also  (figs.) 

6,  10,  95. 

-  Harvey's  Discovery  of,  2,  3,  18(3. 

-  in  Heart,  152-4. 

-  Hypnotics  acting  on,  433. 

-  How  Maintained,  14-5, 154-5. 

-  Local  Modification  of,  by 
Aconite,  253. 

Bleeding,  257-60. 

Heat  and  Cold,  253-7. 

-  -  Hot  Air  Bath,  257. 
Poultices,  255-7. 

-  Obstruction  to,  Cardiac  Murmurs 

Caused  by,  214-5. 

-  Pathology  of,  150  et  sqq. 

-  -  Bibliography  of,  173-4. 

-  Rate  of,  as  affected  by  Viscosity  of 

Blood,  146-7. 

-  Schema  of  (Author's),  94-5,  (fig.)  95. 

-  in  Tissues,  benefited  by  Digitalis, 

308. 

Citrate  of  Potash,  in  Cerebral  Throm- 
bosis, 456 ;  in  Earlier  Treat- 
ment of  Rheumatic  Fever, 
368. 

Citric  Acid,  with  Bicarbonate  of  Soda 
in  Stomach  Acidity,  357 ;  in 
Cerebral  Thrombosis,  456. 


48o 


INDEX 


Clamp,    Compression  by,  of  Frog's 

Heart,  result  of,  81-2,  40,  58, 

(fig.)  82. 
Classification  of  Cardiac  and  Vascular 

Remedies,  284. 
Claudication    and   Angina   Pectoris, 

Views  of  Burns  and  of  Brodie, 

193-5. 
Climate,  effect  of,  on  Action  of  Drugs, 

283 ;  on  Excretion  of  Urine, 

347. 
Clotting  of  Blood,  in  Aneurism,  How 

to  Induce,  454-5 ;  Tendency 

to,  in  Cerebral  Thrombosis, 

How  Met,  456. 
-of  Milk,  Constipation  from,  How 

Met,  430-1. 
Coagulation   of   the  Blood,    Effects 

of,    Diagnostic    Difficulties, 

Wright's  Method  of  dealing 

with,  145-6. 
Cocaine,  Action  of,  on  Heart,  829. 

-  with  Adrenalin,  as  Local  Amesthe- 

tic,  834. 

-  with    Hamamelis    in  Suppository 

for  Pruritus  Ani,  429. 

-  as  Local  Anaesthetic,  261,  334. 

-  Solution    on    Bpicardium    before 

Experiment,  54 ;  on  Pericar- 
dium, Stimulation  Counter- 
acted by,  65,  73. 

-  Use  and   Forms  of,  in  Relief  of 

Pruritus  ani,  430. 

-  as  Vaso-constrictor,  334. 

Coffee,  as  affecting  Cerebral  Activity, 
425. 

-  as  Cause  of  Palpitation,  411. 

-  Contra-indications   for,    415,    420, 

443. 

-  Hot,  Action  of,  in  Faintness,  423. 

-  as  Nerve-stimulant,  318. 

-  Paroxysmal  Bradycardia,  &  Tachy- 

cardia, Induced  by,  168. 

-  Strong,  in  Relief  of   Paroxysmal 

Tachycardia,  418. 
Colchicum,  as  Vaso-dilator,  Action 

on  Rapid  Pulse,  339. 
Cold,  see  also  Heat  and  Cold. 

-  over  Heart,  in  Paroxysmal  Tachy- 

cardia, 418. 

-  -  in  Palpitation  and  Tachycardia 

of  Graves's  Disease,  415. 

-  as     Means     of     Slowing     Pulse- 

rate,  6. 
Cold  Feet,  as   Cause  of   Insomnia, 

How  to  Warm,  426-7. 
Colds,  Febrile,  Aconite  in,  329. 
Colic,  Pain,  Nature,  185. 


Colic,  Pain  (cunt.) 

-  -  Pain  of  Angina  Pectoris  resemb- 

ling. 188. 

-  -  Poultices  to  Relieve,  255. 
Collapse,  Value  in,  of  Adrenalin,  315. 
Collidine,  in  Cigars,  825. 
Colouring  of  Surfaces,  Causes,  7,  8, 

18,  20,  289-90. 
Commodes,  or  Nightstools,  Use  of, 

in  Absolute  Rest  Treatment, 

235,  236,  and  by  Rheumatic 

Fever  Patients,  870. 
Compensatory    Pause    after    Extra 

Systole  in  Frog's  Heart,  46. 
Compound  Jalap  Powder,  best  Hydro- 

cathartic,  858. 
Compresses,  Cold,  Warm,  Wet,  &c.,  in 

-  Insomnia,  255,  482. 

-  Local  Inflammation  and  Pain,  254-5. 
Compression,  of  Carotid,  in  Migraine, 

Author's  Experience,  184,  185. 

-  Effect  of,  on  Medusae,  86. 

-  of  Vagus,  in  relief  of  Paroxysmal 

Tachycardia,  two  Modes  of, 
419. 

Conduction  of  Stimuli,  between 
Auricle  and  Ventricle,  see 
Auricle  and  Ventricle. 

-  -  in  Heart,  by  Nerves  as  well  as 

Muscle,  46-7. 

-  -  Powers  of  the   Vagi  as  to,  68, 


Congeners  of  Digitalis,  311-2. 
Congestion  of  Intestines  Diminished 
by  Massage  and  Rest,  238. 

-  of  Liver,  Diminished  by  Digitalis, 

811,  by  Massage  and  Rest, 
288.     ' 

-  Pulmonary,     in     Aortic     Incom- 

petence, 408. 

-  of  Stomach  Diminished  by  Massage 

and  Rest,  238. 

-  Vascular,  and  Contraction,  as  Cause 

of  Headaches  and  of  Migraine, 

446. 
Conium,  as  used  for  Pruritus  ani,  429, 

430. 
Conjunctivas,  Icteric  Tinge  of,  with 

Cardiac  Irregularity,  Deduc- 

tion from,  382. 
Constipation,    usually    caused     by 

Opium,  277. 
Contractile  Cells,  Capillaries   Com- 

posed of.  84. 

-  Power  (Contractility)  of. 

-  -  Aorta,  84. 

-  -  Arteries,  Source  and  Effects,  7,  8, 

15. 


INDEX 


481 


Contractile  Power  of  (cont.) 

-  -  Arterioles,  Use,  14,  15,   Cause, 

18<Cc. 

Independently  of  Central  Nerv- 

ous  System,  Author's  Re- 
searches into,  271-2. 

—  Carotid  Arteries  and  Branches, 

Brain  Circulation  Regulated 
by,  363. 

—  Pulmonary  Veins,  Service  Ren- 

dered by,  in  Mitral  Regurgi- 
tation,  221. 

-  -  Vagus,  68. 

-  Tissue  in  Medusa?,  34,  35,  (fig.)  84. 
Contracting  Nerves,  85-7. 
Contraction  of  Arterioles  from  Drug 

Action,  see  Arterioles,  Action 
on,  of  Adrenalin,  &e. 

-  -  Chronic,  in  Relation  to  Chronic 

Interstitial  Nephritis,  92. 

-  of  Blood-vessels,  Cardiac  Tonics  as 

Affecting,  Bad  Results  Pos- 
sible from,  312-3,  315. 

-  of  Capillaries,  by 

—  Cold  and  High  Tension  in  the 

Elderly,  182,  (fig.)  ib. 

-  -  Digitalis,  295. 

-  -  Ductless  Glands,  89. 

-  -  Heat  and  Cold,  94. 

in  Relation  to  Diastolic  Pres- 
sure, 113,  116-8,  (fig.)  116. 

-  of  Heart,  see  under  Heart. 

-  Peripheral,  of  Arteries  in  Migraine, 

184. 

-  Pulsatile,  in  Venous  Sinus  of  Frog, 

21. 

-  Rhythmical,    in     Veins,     Source, 

222. 

—  in  Voluntary  Muscle,  How  In- 

duced, 38  n. 

-  Vascular,  and  Congestion  as  Cause 

of  Headaches  and  of  Mig- 
raine, 446. 

-  Ventricular    (Systolic),    see    Ven- 

tricular Contraction. 

-  of  Veins,  S7-S. 

Contraction-Waves  in  Medusfe,  35. 
Contractors,  see  Vascular. 
Convalescence,    from    Acute    Heart 

Disease,  Treatment,  879. 

-  Bradycardia  in,  167 
Convallamarin,  Action  of,  on  Outside 

and  on  Inside  of  Frog's  Ven- 
tricle, 270. 

Convallaria  majalis  (Lily  of  the 
Valley),  311. 

Convulsions,  produced  by  Nicotine, 


Co-ordination  of  Effects  of  Heat  and 
Cold  on  Heart  and  Vessels, 
93-4. 

-of    Heart's    Action,    and    Blood- 
Pressure,  How  Maintained, 
17<e».,  18, 19. 
Corianader,  Oil  of,  Carminative  uses, 

360. 
Coronary  Arteries,  Action  on,  of 

Adrenalin,  315,  333,  334,  344. 

Amyl  Nitrite.  344. 

Caffeine,  344. ' 

Digitalis  (q.v.),  309,  and  Con- 
geners, 344. 

Drugs,  342  et  sqq. 

Nitro-glycerin,  344. 

Theobromine,  344. 

Vaso  Dilators,  344. 

—  Artificial  Circulation  in,  and  the 

Excised  Heart,  26. 

-  -  Atheronia   of,    182,   Seriousness 

of,  214. 

-  -  Blocking  of,  Effects,  152-4,  161. 

-  -  Blood-supply  of,  150-1. 

—  Condition    in   Angina    Pectoris, 

191. 

-  -  Embolism   of    Small   Branches, 

Fibrillation  from,  63. 

-  -  How  they  Supply  the  Heart,  150, 

152-4. 

-  -  Insufficiency  of,  Results,  219. 

—  Ligaturing,  Experimental  Tachy- 

cardia from,  165. 

Fibrillation  from,  63. 

--Nervous  Fibres  observed  in,  85, 

(fig.)  ib. 

—  Obliteration  of  (variously  caused), 

as  Cause  of  Cardiac  Dyspnoea, 
196. 

—  Ossification  of,  Burns'   Experi- 

ments  on,  194,   Brodie   on, 
195. 

—  Plexuses  accompanying,  63,  (fig.) 

54. 

-  -  Right,  Atheroma  of,  in  relation 

to  Breathlessness,  182. 

Interference    with  Circulation 

in,  Results,  445. 

-  -  Sclerosis  of,  Paroxysmal  Brady- 

cardia from,  168. 

—  Spasm  of,  Pains  caused  by,  see 

False  Angina,  and  Migraine. 

-  -  Lymphatics,  154. 

-  Vein,  in   Diastole,   154,  Effect  of 

Ligaturing,  153. 
Corrmilla,  311. 
Corsets,  Constriction  by,  Effects, 227-S 

-  Loosening  of,  in  Fainting,  228. 


482 


INDEX 


Cortical  Substance  of  Suprarenal 
Glands,  Disease  of,  as  affect- 
ing Skin-colour,  289-90. 

Coryza,  from  Iodides,  842. 

Cough,  from  Excessive  Smoking,  827. 

-  in  Mitral  Stenosis,  407. 
Coughing,  Mechanism  of,  228;  Violent, 

Effects  on  Heart,  229,  Pul- 
monary Obstruction  occur- 
ring during,  172. 

Coupled  Pulse,  see  Bigeminal. 

Cradle  for  Bed-clothes,  use  of  in 
Insomnia,  428,  and  Rheu- 
matic Fever,  871. 

Cranial  Circulation,  and  Headache 
of  Menstrual  Period,  449. 

Creosote,  as  Gastric  Antiseptic,  856. 

Cricket,  Restrictions  on,  for  Cardiac 
Patients,  252. 

Crochets  or  Hooks  in  Pulse-tracings, 
130,  (fig.)  ib. 

Croton  Oil,  in  Cerebral  Haemorrhage, 
456. 

Crossing  Streets,  Warning  on,  for 
Elderly  Persons  suffering 
from  Giddiness,  424. 

Cupping,  Relief  from,  257-8. 

Curare,  Action  of,  in,  and  on 

•  -  Large  and  Small  Doses,  275. 

-  -  Medusae,  36. 

-  -  Vagus,     Paralysing     Inhibitory 

Fibres,  71-2. 
Cure,  Essentials   to,    Best   Secured 

away  from  Home,  409. 
Cutaneous  Blood-vessels,  Contraction 

and  Dilation  of,  7,  18,  20. 
Czerrnak,  experience  of,  with  Vagus 

Compression,  187  &n. 


DAILY  Matutinal  use  of  Nitrate  of 
Potash  and  Nitrite  of  Sodium 
in  High  Tension,  453. 

Dancing,  Systolic  Murmur  induced 
by,  217. 

Deafness,  Headache  from,  447. 

Death  and  Cessation  of  Blood  Circula- 
tion, 12-13;  Empty  Arteries 
after,  3,  8, 13,  19. 

Deaths  from 

-  -  Acute  Heart  Disease,  How  gener- 

ally Occurring,  367. 

-  -  Atropine,  How  Induced,  274-5. 

-  -  Fermentation  of  Food  in  Stomach, 

How  Caused,  226-7,  (fig.)  226. 

-  -  High    Tension,    Usual    Forms, 

452. 

-  -  Straining  at  Stool,  228. 


Deaths,  Sudden,  from 
---  Aortic      Regurgitation,     Fre- 

quent, 404. 
---  Blocking  of  Coronary  Arteries, 

158. 
---  Ingestion  of  Large  Quantities  of 

Alcohol,  178. 
---  Rupture    of    Cerebral    Blood- 

vessel, 202. 
---  Wet  Pack,  Reason,  432. 

-  -  Risk  of,  in  Angina  Pectoris,  404, 

Classic  Case,  189. 

Debility,  after  Acute  Disease,  Dilata- 
tion in,  217;  Pituitrin  in, 
How  Best  Given,  320. 

-  Palpitation  in,  176;  Treatment,  414. 
Decayed  Teeth,  as  Cause  of  Headache, 

446-7. 
Deep  or  Posterior   Cardiac    Plexus, 

Right  and  Left  Divisions  of, 

63,  cf.  67. 
Defecation  (see  also  Evacuation),  Aids 

to,  Straining  at  Stool  to  be 

Avoided,  396,  cf.  172. 
Defibrinated   Blood,  as  Affected  by 

Heat,  &c.  ,  147  ;  as  Nutrient 

in  Artificial  Circulation,  278. 
Degeneration,  see  Fatty,  Fibroid,  & 

Parenchymatous. 

Dend  rons  of  Neurons  ,  Nature  of,  200  n. 
Depressants,  Cardiac,  284,  823  et  sqq. 
Depressed  Circulatory  Conditions, 

Value  in,  of  Pituitrin,  819. 
Depression,  General,  from  Shock,  177. 
Depressor    Nerves  in    Man,  21,  65, 

in  Rabbits,  65. 

Diabetes,  Bradycardia  in,  167. 
Diaphragm,  Action    of,    in   Upright 

and  in  Horizontal  Positions, 

234. 
Diarrhoea,  Blood-pressure  Low  in.  181. 

-  from  Over-peptonised  Milk,  431. 

-  of  Renal  Tubules,  Result  (probable) 

of  Action  of  Salines,  350. 
Diastole,  or  Rest-  period  of  the  Heart, 
4-0,  (figs.)  6,  16. 

-  Arterial  Coats  at,  action  of,  157, 


-  -  Condition  in,  154. 

-  in    Frog's    Heart,    Effect    on,    of 

Electrical    Stimulation,    44, 
(fat.)  «. 

-  Long,  under  effect  of  Digitalis,  308, 

307;    Overlong   (Standstill), 
from  Excess  of  Potassium  and 
Stimulation  of  Vagus,  286. 
-Shortened,  Gallop  Rhythm  from, 
211-2.    - 


INDEX 


483 


Diaitolic    Blood-pressure,     defined, 
112-3 ;    Difference   of,    from 
Systolic,  115,  in  Aortic  Re- 
gurgitation,  404-5;  Measure- 
i  ment  of,  113-4,  Instruments 

for,    114-5 ;  relation    of,    to 
Systolic,  115  et  sqq. 

-  Bruit  or  Murmur 

—  Indicative  of  Aortic  Incom- 
petence, 214-5,  Where  Heard, 
ia  Aortic  Regurgitation,  407. 

-  Dilatation,  Action  on,  of  Digitalis, 

299. 
Dichrotic      Pnlse,      Cause,      180-1, 

(fig.)  131 ;  as  shown  bySphyg- 

mbgraph.  138. 
Diet  in 

-  Aortic  Stenosis,  403. 

-  Cerebral  Thrombosis,  456-7. 

-  Cardiac  Disease,  252-3. 

-  Convalescence  from  Acute  Heart 

Disease,  379. 

-  Graves's  Disease,  415. 

-  Insomnia,  430-1. 

-  Paroxysmal  Tachycardia,  in  Gouty 

Persons,  419. 

-  Rheumatic  Fever. 

-  -  Febrile  stage,  372-3. 

-  -  Post-febrile  stage,  373. 

-  Senile  Condition  of  Blood-vessels, 

452. 

-  Sugar  Treatment  of  Failing  Heart, 

on   Goulston    and    Carter's 
Method,  287. 

-  to  Aid  Defecation,  396. 

-  Effect  of,  on  Excretion  of  Urine, 347. 

-  Error  of,  as  Cause  of  Urticaria,  450. 

-  Solid  and  Liquid,  Best  given  Separ- 

ately, 355,  374,  384. 

Dietetic  Rules,  in  Oertel's  Treat- 
ment, 250-1 ;  to  Prevent 
Flatulence,  355. 

Digalen,  Action  of,  on  Dogs  with 
Fatty  Heart  (Scalfati),  314. 

Digestion,  Attention  to,  in  Heart 
Disease,  Importance  of,  867, 
380,  382  et  sqq. 

-  Effect  on,  of  Digitalis,  311. 

-  Fluid  at  Meals  as  affecting,  355, 

374,  384. 

-  Improvement   of,    by    Rest    and 

Massage,  238 ;  by  Treatment, 
for  Low  Tension,  451. 

-  Intestinal,  Process  of,  393. 

-  in  relation  to  Palpitation,  226,  411, 

439. 

-  Salivary  Secretion,  How  Assisting, 

384,  386. 


Digestive  Ferments,  in  Tachycardia 
419. 

-  Organs,  Disease  of,  Cause  of  Feeble 

Heart  and  Pulse,  158. 

-  System,  Action  on,  of  Drugs,  &c., 

346,  856  et  sqq. 

Digestives,  as  Reinforcing  Drugs 
acting  directly  on  Circula- 
tion, 284. 

Digitalin,  Action  of,  on  Dogs  with 
Fatty  Heart  (Scalfati),  314. 

-  -  on  Heart,  438. 

-  -  on    Outside,    and  on  Inside,  of 

Frog's  Ventricle,  270. 
Digitalis 

-  Action  of 

-  -  as  Affected  by  Temperature,  281. 

-  -  Drawbacks  to,  812,  Removal  of, 

by  Combination,  313. 

-  -  Historical    Sketch    of,    Experi- 

ments of  Blake,  Traube,  and 
Author,  295-6. 

-  -  Physiological,  Author's  Descrip- 

tion of  (the  earliest)  cited,  296. 

-  -  Resume,  307-8. 

-  -  Stages  in,  301-3,  (fig.)  302. 

-  Action  of,  in 

-  -  Aortic  Regnrgitatibn,  how  Best 

Given,    406-7 ;     Precautions 
Necessitated,  405. 

-  -  Bright's  Disease,  Need  of  Caution, 

313. 

-  -  Cardiac  Asthma,  445. 

-  -  Endocarditis,    When    Indicated, 

376. 
—  Insomnia,  432. 

-  -  Intervals  of  Paroxysmal  Tachy- 

cardia, 418. 

-  -  Mammals,  298. 

-  -  Mitral  Regurgitation,  409. 

-  -  Palpitation,  418. 

-  -  Pericarditis,  on    Kidneys,    877 ; 

Form  Preferred  by  Author,i6. 

-  -  Stokes- Adams  Disease,  421. 

-  -  Poisonous  Doses 

-  -  Author  on,  296. 

Symptoms  of,  303-4. 

on  Apex-beat  in  Animals,  175-6. 

-  -  on  Heart,  217,  274,  295. 
on  Nervous  System,  298. 

-  -  on  Pulse. 

Bigeminal  Pulse  from,  170. 

Bradycardia  from,  168. 

Earlier  and  Later,  814  5. 

•  -  Tracings  of  (/<?,*.),  805. 

-  Action  of,  on 

-  -  Arterioles,  299-301. 

-  -  Cardiac  Muscle,  307. 


484 


INDEX 


Digitalis,  Action  of,  on  (font.) 

-  -  Circulation,  as  Hypnotic,  438. 

-  -  Coronary  Arteries,  848. 

-  -  Embryonic  Heart.  297-8. 

-  -  Heart  and  Vessels,  117, 155,  299, 

802-8,  812-8,  483,  440,  (figs.) 
117,  299,  302  ;  Triple  Nature 
of,  294,  295. 

Risks    of,    in     Fatty    Heart, 

Author's  Warning,  814. 

-  -  Kidneys,  803,  804,  305-9,  812 ;  in 

Venous  Congestion,  809-10. 

-  -  Medulla,  308. 

-  -  Nervous  System,  298. 
--Pulse,    Tension,    <tc.,    61,    117, 

(fig.)W. 

-  -  Vagus   Centre,  298,  818  ;   Effect 

on  Cardiac  Pulsation,  61. 

-  -  Vanus  Roots,  303. 

-  Cardiac  Nutrient  as  well  as  Stimu- 

lant, 155-6. 

-  Centra-indications  for,  420. 

-  Four  Different  Principles  in,  278. 

-  Congeners    of    (Digitalis    Group), 

304,  307,  311-2 

-  -  in  Combination  with  one  of  the 

Diuretics  Group,  319. 

-  -  Coronary  Arteries  Dilated  by ,  344. 

-  -  Differences  between,  312. 

-  -  Drawbacks   to,   How  Removed, 

812-3. 

-  -  in  Graves's  Disease,  416. 

-  -  How    Increasing   Amplitude   of 

Pulse,  158. 

-  -  as  Vaso-constrictors,  334-5 

-  and   Similarly-acting  Substances, 

Action  of,  on  Kidney  Circula- 
tion, 349. 

-  Effects  of,  in  Large  and  in  Small 

Doses,  277. 

-  Squill  and  Blue  Pill,  as  Cardiac 

Diuretic,  350;  in  Mitral 
Disease,  253. 

-  Tinctureof,  withSalicylateof Soda, 

in  Cardiac  Failure  of  Acute 
Rheumatism,  375. 

-  Uses,  308-11. 

Digitoxin,  Action  of,  on  Dogs  with 
Fatty  Heart  (Scalfati),  314 

Dilatation  (see  also  Distention  £  Vaso- 
Dilators)  of 

-  Abdominal  Blood-vessels  by  Warm 

Poultice,  &c.,  432. 

-  Aorta,    Nature   of  Second  Sound 

with,  211. 

--  Arterioles,  due  to  Local  Irritation, 
Observations  on,  of  Author, 
Gunning  &  Cohnheim,  87. 


Dilatation  of  (cont.) 

-  Arteries  in  Migraine,  184. 

-  Bladder,  in  relation  to  Tone,  289. 

-  Blood-vessels  Aimed  at,  in  Treat- 

ment  of  Angina  Pectoris,441. 
—  by  Local  Application  of  Heat, 
254-6. 

-  -  by  Rubbing  and  Cold  Water.more 

lasting  than  from  Immersion 
of  Feet  in  Hot  Water,  427. 

-  of  Capillaries,  &c.,Active,  Author's 

Hypothesis  of  Transverse 
Contraction  of  Muscular  Cells 
of  Heart,  to  explain,  270-1. 

-  Heart,  Active,  55. 

-  -  from  Cardiac  Strain,  &c. ,  217. 
--Diagnosis   of,    Differential,  877; 

X-ray,  138. 

-  -  Diastolic,  Effect  on,  of  Digitalis*, 

299. 

--Diminished  by  Digitalis  (q.v.), 
809 ;  by  Nauheim  Treatment, 
Author's  Personal  Observa- 
tions on,  249. 

-  -  Pituitrin  in,  How  Best  Given, 320. 

-  -  in  relation  to  Tone,  289. 

-  -  Ventricular,  Causes,  218-9. 

-  Intestine,  Action  of,  on  Vagus,  438. 

-  Renal  Blood-vessels,  by  Drugs  (see 

also  Digitalis),  347,  349. 

Dilating  Nerves,  86-7. 

Dill  Water,  as  Carminative  for  In- 
fants, and  for  Adults,  862; 
in  Enema,  361. 

Dimethyl-xanthine,  288. 

Diphasic  Variation  in  Electro-cardio- 
grams, 141. 

Diphtheria,  Blood-pressure  Low  in, 
and  After,  181. 

-  and  Fatty  Degeneration,  152, 160-1. 

-  Heart-weakness       after,       Triple 

Causes,  160-1. 

-  -  Bradycardia  during,  167-8,  Treat- 

ment, 420-1. 

-  Paralysis  of  Vagi  from,  Pulse-rate 

in,  163. 
Diphtheria   Bacillus,    Effect  of,    on 

Myocardium  and  on  Vagus, 

152. 
Diphtheritic     Antitoxin,    Urticarial 

Rash  from,  199. 
Discharge,  Aural ,  Headache  from  ,447. 

-  Profuse,Blood-pressureLowin,181. 
Discomfort,     Cardiac     Altitude     in 

relation  to,  250. 

-  during  Rest   Treatment,   Causes, 

and  Means  of  Relieving,236-9. 

-  without  Pain,  Organs  Feeling,  186. 


INDEX 


485 


Diseases,  Chronic,  Debility  from, 
Blood-pressure  Low  in,  181. 

-  of  the  Heart,  see  under  Names  ;  see 

also  Organic  Diseases. 
Disinfectants,  Intestinal,  369-60. 
Disordered  Circulation 

-  Bibliography  on,  206-9. 
—  Symptoms  of,  175  et  sqq. 
Distention,  see  Gastric,  <£  under 

Names    of    Parts    suffering 

Distention. 

-  in  relation    to    Angina    Pectoris, 

189-90. 

-  Internal,  Pain  felt  from,  by  Hollow 

Muscular  Organs,  186. 

-  Intestinal,  Carminatives  for,  361. 
Diuretic  Action  of 

-  Caffeine  and  other  Purin  Bodies, 

317,  318-9. 

-  Digitalis,  296,  303,  306-7,  308-10. 

-  Lactose,  253. 

-  Pituitary  Secretion,  90,  319. 
Diuretic(s),  346-8;   Five  Groups  of, 

Action  of,  and  Adjuncts  to, 
348  et  sqq. 

-  Synthetic  and  Natural  Group  of, 

317-9;  Use  of,  in  Combination 
with  Digitalis  and  its  Group, 
319. 

Diuretin,  318. 

Dog,  Blood-pressure,  Normal,  and 
under  Digitalis,  96,  300; 
Carves  of,  by  Meyer  and 
Author  (.figs.),  117,  300. 

-  Circulation    in,    Maintained     by 

Vessels  of  Thebesius  after 
Block  of  Coronary  Arteries, 
153. 

-  Heart  of,  Action  on,  of  Right  and 

Left  Vagus  (fig),  69. 

-  -  after  Digitalis  Poisoning,  Mitral 

Regurgitant  Murmur  in,  217. 

-  -  Extra  Systole  in,  from  Stimula- 

tion of  Pericardium,  65. 
—  Fatty,  Scalfati's  Experiments  on, 

314. 
-  Fibrillation  in,  usually  Fatal,  63. 

-  -  Stoppage  of,  from  Inhalation  of 

Ammonia  or  Chloroform,  73. 

-  Intravenal  Injection  in,  of 

-  -  Digitalis,  Effect  on  Arterial  Pres- 

sure, 299,  300-1,  (fig.)  299. 

-  -  Opium  (large  Dose),  Effects  of, 277. 

-  Left  Ventricle  of,  Blood-pressure 

overcome  by,  18, 19. 

-  (Edema,  in,  Experimental,  due  to 

Vaso-motor  Nerve  weakness, 
224. 


Dog  (cont.) 

-  Vena  Cava  in,  Tying  of,  Ranvier's 

Experiment     in     regard    to 

Venous       Congestion      and 

(Edema,  310-11. 
Dorsal  Nerves,  certain,  Blisters,  &c., 

over,    in   relief   of    Cardiac 

Pain,  441. 
Dosage,  see  also  Amyl  Nitrite,  How 

Best  Given,  &  Overdose. 

-  Difference  in,  as   Affecting  Drug- 

action,  273,  277. 

Douches,  for  Nasal  Irritation,  447. 
Dover's   Powder,  Value  of,  364 ;    ia 

Endocarditis,  376. 
Draughts,     Avoidance      of,      while 

Sponging   Rheumatic   Fever 

Patients,  370-1. 
Drinks  for  Rheumatic  Fever  Patients, 

373. 

Dromotrope,  56. 

Dropsy,  see  Ascites,  Effusion,  (Edema. 
Drugs,  see  also  under  Names. 

-  Action  of 

—  Contradictory  Results  of  Investi- 
gation of,  Reasons  and  Need 
for  Care  in  Drawing  Conclu- 
sions, 281-2,  283-4. 

--on  Blooil-vessels,  21,  332; 
Methods  and  Apparatus  for 
Ascertaining,  271-2. 

Circulation,  266-7. 

Coronary  Arteries,  342  et  sqq. 

Frog's  Heart,  Investigation  of 

Apparatus  for,  267  tt  sqq., 
(/</.)  268. 

Urinary,  Digestive,  and  Nerv- 
ous Systems,  346  et  sqq. 

Bibliography,  365. 

Vagus,  67. 

-  -  Modification  of,  or  Interference 

with,  by  or  from. 
Chemical  Condition  of  Blood, 

273,  278-9. 

Climate,  283. 

Condition  of  Body,  273,  278-9. 

Dosage,  273,  277. 

Inurement,  273,  279-80. 

Season  of  Year,  282. 

Temperature  of  Body,  273, 281 -2. 

Vary  ing  Composition,  273, 277-9. 

-  -  Peripheral  and  Central,  273,  276. 

-  -  Selective,  273,  274-5,  332-3. 

-  Affecting  Tissue  Change  and  Blood 

Composition,  Indirect  Action 
of,  on  Heart  and  Vessels,  284. 

-  as  Cardiac  Tonics,  also  Acting  as 

Nutrients,  155-6, 158. 


486 


INDEX 


Drags  (cont.) 

-  for  Acute  Rheumatism,  374-5. 

-  -  Cardiac  Asthma,  445. 

-  -  Lowering  Arterial  Tension,  413. 

-  -  Provoking  Insomnia,  304. 

-  -  Relief  of  Headache,  Best  Sorts, 

448. 

-  -  Slowing  Pulse,  6. 

-  Ineffective  in  Mitral  Stenosis,  407. 
Dry  Cupping,  Hypothetical  Explana- 
tion of  Mode  of  Action,  258. 

Ductless  Glands,  Secretions  of. 

-  Action  of,  on  Blood-pressure,  89  et 

sqq. 

-  -  on  Tissue-Metabolism,  38. 

-  High  Importance  of,  89-90. 
Dudgeon's  Sphygmograph,  127,  135; 

Author's  Addition  to,  129; 
Tracings  Produced  by  Differ- 
ent Applications  with  the 
Same  Pulse  (figs.),  133,  134, 
135. 

Duodenal  Ulcer,  and  Abdominal 
Pulsation,  177. 

Dysentery,  Blood-pressure  Low  in, 
181. 

Dyspepsia,  Action  on,  of  Alkalies,  431. 

-  Bicarbonate  of  Soda,  to  Lessen,  387. 

-  Bitters  of  use  in,  388. 

-  False  Angina  from,  193. 

-  and  Gastric  Catarrh,  from  Post- 

nasal  Catarrh,  390-1. 

-  Paroxysmal  Tachycardia  from,  419. 

-  Reflex  Stimulation  in,  of  Vagus, 

Bradycardia,  from,  167. 

-  Tooth-deficiency,  &c. ,  as    Causes 

of,  382-3. 

Dyspnoea,  Cardiac,  Causes  and 
Nature,  182,  196-7,  445. 

EAR-AFFECTIONS,  Giddiness  from, 201. 

-  Headache  from,  447. 

Ear  of  Rabbit,  Effect  in,  of  Blood, 
Poisoned  and  other,  Appar- 
atus for  Examining  (fig.),27l. 

Ears,  as  affected  in  Faintness,  422. 

Ectopic  Ventricular  Contraction,  58. 

Eczema,  Insomnia  from,  429. 

Egg-albumen,  non-Nutrient  to  Heart, 
286. 

Eggs,  as  used  in  Mitral  Disease,  253. 

Ehrlich's  Schema  of  a  Cell  in  relation 
to  Inurement  to  Poisons,  280. 

Einthoven's  Method  for  Lettering 
Electro-Cardiograms,  141 ,144. 

-  String  Galvanometer,  Nature  and 

Use  of,  189  <en.,  140-1,  (fig.) 
142. 


Elaterium,  or  Compound  Powder  of 
Elaterin,  Action  of,  858. 

Elderly  People,  see  also  Old,  £ 
Senile. 

—  Cardiac  Murmurs  in,  from  Aortic 

Atheroma,  214. 

-  -  Chilblains  of,  Treatment,  450. 

-  -  Effects  on,  of  Grief,  Worry,  ami 

Anxiety,  159-60. 

-  -  Giddiness  in,  Causes,  201. 

—  Labyrinthine    Vertigo    in,    Re- 

medies and  Risks,  423,  424. 

--with  High  Tension,  Capillary 
Contractions,  132,  (fig.)  ib. 

Electric  Changes  accompanying  Car- 
diac Movements,  Instruments 
for  Detecting,  Use,  and  Users, 
139-45,  (figs.)  142-4. 

-  Shocks,    Recovery   by,   of    Dogs' 

Hearts  from  Ventricular 
Fibrillation,  63. 

-  Stimulation,  Fibrillation  from,  55, 

68. 

—  to  Aorta,  Effects,  84. 

--to  Frog's  Heart,   Effects,  44-7; 
Deductions,  47,  (figs.)  43,  45. 
Apex  of,  Excised,  30. 

-  -  to    Heart,    Effect    on     Cardiac 

Nerves,  55. 

to  Epicardium,  Effect  on  Car- 
diac Sensory  Nerves,  54. 

-  -  to  Medulla  or  Vagus,  Inhibitory 

Action  induced  by,  on  Frog's 
Heart,  39. 

-  -  to  Vagus,  Effect  of  Blood-pressure 

in  Dog  (fig.),  800. 

-  -  to  Vagus  Trunks,  Effect  on  Car- 

diac Pulsation,  61. 

-  Treatment  in 

-  -  Angina,  444,  454. 

-  -  Cardiac  Pain,  441. 

—  High  Tension,  454. 
Electro-cardiograms,  Contraction  of 

the  Heart  as  shown  by,  55. 

—  Deflection  groups  in  three,  des- 

cribed, 141. 

-  -  Diagrams  of  (figs.),  143,  145. 

—  Diphasic  Variation  in,  141. 

-  -  Methods  of  Obtaining,  and  Uses 

of,  139  et  sqq.,(figs.)  143,  145  ; 
Letters  Designating  Parts, 
142-8  ;  table  of,  144. 

-  -  in  Tachycardia,  Indication  from, 

165. 
Electro-cardiograph,  189,  Leads  of, 

140-1. 
Electrometer,  Capillary,  use  of,  by 

Marey,  and  others,  139. 


INDEX 


487 


Eliminants,  Reinforcing  Drugs  acting 
directly  on  Circulation,  284. 

Eliminating  Organs,  Stimulation  of, 
398. 

Elimination  of  Waste  Products,  in 

-  -  Heart  Disease,  238,  367,  897-8, 403. 

-  -  Rheumatism,  Acute,  375. 
Elixir  Glusidi,  with  lod.  Pot.,  Pre- 
scription, 341-2. 

Elongation  of  Muscle,  85-7. 

Embolism,  Causes  and  Results,  204-6, 
(#0s.)205,  206;  Difficulty  of 
Differentiating  from  Throm- 
bosis, 205. 

-  of  Coronary  Arteries,  Causes  and 

Results,  152-3. 

-  of  Sylvian  Artery,  Apbasiafrom, 205. 
Embryonic    Heart,   Action    on,    of 

Cardiac  Tonics,  297-8. 
Emetics  (sec  also  Tartar  Emetic)  for 

-  Paroxysmal  Tachycardia, 164-5,418. 

-  Stomach  Irritation,  <3S. 

-  Urticaria,  450. 
Emotion,  Effect  of,  on 

-  -  Blood-pressure,  7,  112,  188,  190. 

-  -  Pulse-rate,  159, 163,  (fig.)  164, 194. 

-  -  Second  Heart  Sound,  210-11. 

-  -  Vagus,  158-9. 
Emphysema,Breatlilessness  from,  182. 

-  Cardiac  Weakness  from,  228. 

-  Effect   of,  on    First   and    Second 

Heart  Sounds,  211,213. 

Endarteritis,  Syphilitic,  Cerebral 
Thrombosis  from, Treatment, 
457. 

Endocarditis,  Absolute  Rest  Speci- 
ally Important  in,  369. 

-  Acute,  Causes  and   Outlook   for, 

367-8. 

-  Associated  with  Rheumatic  Fever, 

Causes,  151-2,  Indication  of, 
376. 

-  Septic,  Micro-organisms  Causing, 

Route  of  Entry  of,  Symptoms 
and  Treatment,  378. 

-  Temperature  Variations  in,  367-8; 

Regulation  of,  376. 

-  Ulcerative,  Fatal,  from  Pyorrhoea 

alveolaris,  883. 
Enemata,  to  Aid  Defecation,  396. 

-  -  of  Asafoetida,  in  Intestinal  Dis- 

tention,  361. 

-  -  of  Dill  Water,  as  Carminative, 361. 

—  of  Tobacco,  former  use,  324. 

—  qf  Warm  Water,  in  Pruritus  ani, 

429. 

-  Nutrient,  in  Cerebral  Hemorrhage, 

450. 


Engorgement,  see  Heart.  Right  Side, 

and  Venous. 
Entero-hepatic  Circulation,  Poisons 

in,   354,   395,  (fig.)  ib.,  443; 

Action  on,  of  Digitalis,  311. 
Enzymes,  Nature  and  Functions  of, 

391. 
Epicardium,  Action  of  Cocaine,  329. 

-  Electric  Stimulation  to,  Effect  on 

Cardiac  Sensory  Nerves,  54. 

-  Intrinsic    Afferent      Nerves     in, 

Functions  of,  53-4,  64. 

Epigastrium,  Blow  on,  Shock  from, 
Goltz's  experiment,  175, 
(fig.)  ib. 

Epilepsy  and  Migraine,  du  Bois  Ray- 
mond's views  on,  Author's 
own  observations,  186. 

-  Raynaud's      Disease      associated 

with,  197. 

Ergot  and  Adrenalin,  Rhythmic 
Contraction  induced  by,  in 
Strips  of  Vessels,  88. 

Erlanger's  Recording  Sphygmoman- 
ometer,  115. 

Eruptions  induced  by  Iodides,  Treat- 
ment, 342. 

Erythrocyteg,9. 

Erythrophlcewm  guineense,  Medicinal 
Uses,  311. 

-  Action  of,  chiefly  on  Vessels,  312. 

-  -  on  Kidneys,  304,  307,  (fig.)  306. 
Eserine,  in  Paroxysmal  Tachycardia, 

418. 

Essential  Oils,  as  Carminatives,  360. 

Estimation  of  Blood-Pressure,  Instru- 
ments for,  15-6. 

Ether,  Effect  of,  on  Medusa;,  36. 

-  as   Cardiac   Stimulant   in    Endo- 

carditis, 377. 

-  Spirit  of,  as  adjunct  to  Cardamoms 

as  Carminative,  362. 

-  Spray,  as  Local  Anaesthetic,  261. 
Ethereal  Oils,  as  Diuretics,  350. 
Ethyl  Carbamate,  as  Hypnostic,  435. 

-  Iodide  of,  in  Cardiac  Asthma.  445 ; 

How,  and  When,  Given  with 
Oxygen,  241-8,  (figt.)  242,  243. 

-  Nitrite  of,  as  Diuretic,  350. 
Eucalyptus,  Oil  of,  in  Septic  Endocar- 
ditis and  Pericarditis,  378-9. 

Eustenin  (lod.  Sod.  and  Theobrom.) 

as  Diuretic,  318. 
Evacuations,  see  also   Defecation   <6 

Excretion. 

-  Arrangements  for,  during  Treat- 

ment    by     Absolute     Rest, 
234  et  snn. .  370. 


INDEX 


Evacuations,  Delayed,  danger  of,  894. 
Examination  of 

-  Blood-pressure  in  Man,  100  etsgiy. 

-  -  Bibliography,  120-2. 

-  Circulation,  123  et  sqq. 

-  -  Bibliography,  148-9. 
Excitation-wave,  Course  and  Effects, 

68-9,  cf.  40. 

Excitement  (see  also  Emotion),  Avoid- 
ance of,  in  Heart  Disease,  869. 

-  Effect  on  Pulse-rate,  163,  (fig.)  164. 

-  Mental,  and  Irritation,  Sedatives 

for,  in  Palpitation,  413. 

-  Tobacco-smoking  as  Soothing,  826. 
Excretion   (see    also    under    Urine), 

Process  of,  397-8 ;  Importance 
of  heed  to,  398. 
Exercise,  as  aid  to  Metabolism,  396. 

-  for  CardiacPatients, Rules for,251-2. 

-  in  Chronic  Heart  Disease,  367. 

-  Danger   of,    with   Ossification    of 

Coronary  Arteries,  Burns's 
experiment  on,  194. 

-  Effect  of,   on   Pulse   and   Blood- 

pressure,  110-11,  (fig.)  111. 

-  Massage  as  Substituts  for,  in  Best 

Treatment,  236  et  tqq. 

-  Moderate,  Why  good  for  Heart,  397. 

-  of  Muscles,  Benefit  of,  to  them- 

selves, 897. 

-  Open-air,  in  Graves's  Disease,  415, 

416. 

-  Severe,  Occasional  good  Effects  of, 

in  Adherent  Pericardium,437. 

-  Violent,    Risks    from,    to    Heart, 

216,  217. 

-  without  Strain,  in  Aneurism,  464-5. 
Exercises  for  Evacuation  of  Bile,  896. 

-  Gentle,  in  Cardiac  Asthma,  445. 

-  Graduated,  in 

-  -  After-cure  for  Nauheim  Treat- 

ment, 249-50. 

-  -  Aortic  Regurgitation,  404. 

-  -  Bradycardia    of    Fever   Conval- 

escence, &c.,  421. 

-  -  Low  Tension,  for  Digestion,  451. 

-  -  Oertel's  Treatment,  250-1. 

-  -  in    Rest    Treatment,   effects   of, 

239-40,  (Jig.)  240. 

-  for  Increasing  Pulse  vigour,  157-8. 

-  in  Nauheim  Treatment,  244  et  sqq., 

(fig.)  246. 

Exertion,    Angina    Pectoris    caused 
by,  188,  190. 

-  Danger   of,    with    Ossification   of 

Coronary  Arteries,  Burns's 
experiment,  Brodie's  views 
on,  194-5. 


Exophthalmic  Goitre,  Palpitation  in, 
Causes  and  Treatment,  415. 

-  -  Pulse-rate  in,  165. 

-  -  Throbbing  of  Arteries  in,  177. 
Experimental  Aortic   Regurgitation 

in  Rabbits,  406. 

Expiration  against  Resistance,  Val- 
salva's  Experiment,  228. 

-  Altered   Pressure    in    Pulmonary 

Artery  at  Beginning  of,  and 
the  Second  Sound,  211. 

Expulsion  of  Bile, Chief  agent  in, 395-6. 

External  and  Internal  Secretions, 
391-3. 

Extra  Systole,  Nature  and  Causes,  46, 
53-4,  64-5,  171-8;  as  substi- 
tute term  for  Bigeminal 
Pulse,  169-70. 

Extraction  of  Teeth,  when  Essen- 
tial,  388. 

Extremities,  Keeping  Warm,  in  Ray- 
naud's  Disease,  450. 

-Throbbing  in,  177. 

Extrinsic  Nerves  of  Heart,  63  et  sqq. 

Exudation  of  Fluid  (see  also  (Edema) 
in  Venous  Engorgement,  223, 
Results,  224. 

Eyeballs  (see  also  Pupil),  Gentle  Mas- 
sage of,  for  Insomnia,  429. 

Eye  Troubles,  Headache  from,  446, 
Treatment,  447. 

FACE,  Flushing  of,  from  Emotion,  7-8. 

-  and  Ears,  Sponging  of,  for  Faint- 

ness,  422. 

Facial  Aspect,  in  Aortic  Regurgita- 
tion, 219,  404. 

Faeces,  Human,  Bacilli  from,  Amines 
from,  acting  like  Supra- 
renal Extract,  91. 

Failing  Compensation,  with  Cardiac 
Hypertrophy,  Cerebral  and 
Cardiac  Symptoms  in,  219. 

-  Heart,  Sugar  Treatment  of,  253,287. 
Failure    of    Heart,    from    Digitalis, 

301-8. 
Fainting     and     Faintness,    Causes, 

Treatment,  168, 180,  200,  219, 

228,  421-3. 

Falling,  in  Fainting,  422. 
False  Angina,  Author's  Observations 

on,  195,  &  with  others,  196. 
Farinaceous      Foods,      Sugar-made, 

Saltless,  in  Mitral  Disease, 

253. 
Fascia,  Hard,  Pain  below,  relieved  by 

Cold,  254. 


INDEX 


489 


Fascife  of  Limbs,  Aid  given  by,  to 

Circulation,  11-12,  229. 
Fasting.  Effect  of.  on  Powers  of  Liver, 

'395. 
Fatigue,  the    Limiting    Factor,    in 

Exercise  by  Cardiac  Patients, 

252. 

Fats,  Digestion  of,  393. 
Fatty  Degeneration. 

-  -  Associated  Conditions. 

Bradycardia,  167, 168. 

Breathlessness,  182. 

Cardiac  Asthma.  445. 

—  Cardiac  Weakness,  158. 

-  Low  Blood-pressure,  181. 
-  -  Tachycardia,  165,  417. 

-  -  Causes  and  Results,  151, 152, 153, 

160-1,  228. 

-  -  Digitalis  in   Cases  of,  Author's 

Warning  on,  reiterated  and 
supported  by  Scalfati,  314. 

-  -  in  Rabbits  and  Fowls  after  Vagus- 

section,  160. 

Febrile  Colds,  Aconite  in,  329. 
Feeling    Pulse   by    Finger-pressure, 

100-1,  114,  119-20,  128-9. 
Feet  and  Ankles,  as  affected  by  Venous 

Engorgement,  223. 

-  Cold,  as  Cause  of  Insomnia,  How 

to  Warm,  426-7. 

-  Heat  to,  in  relief  of  Headache,  448. 

-  Ointment  for,  in  Raynaud's  Dis- 

ease, 450. 

-  Putting  into  Hot  Water,  Dilatation 

of  Vessels  from,  Author's 
Experience,  254. 

Femoral  Arteries,  Effect  on,  of  put- 
ting Feet  into  Hot  Water,  254. 

Fermentation,  Gastric,  Causes,  Re- 
sults, 355,  857,  386;  Death 
from,  226-7,  (fig.)  226. 

Ferments,  Digestive,  in  Relief  of 
Tachycardia,  419. 

Feverishness,  Sponging  for,  428. 

Fevers,  Blood-pressure  Low  in,  181. 

-  Bodily  Temperature  Increased  in, 

Double  Effect  on  Pulse,  94. 
-  Cardiac  Muscle   weakened  by,  152, 
and  Effects  on  First  Heart 
Sound,  212. 

-  Infective,    Toxins   occurring    in, 

effect  of,  on  Heart  Structure, 
152. 

-  Insomnia  in,  364,  865. 

-  One  of  Nature's  Defences,  451,  452. 

-  Pulse-rate  in,  163. 

Fibres,  see  Block,  Muscular,  Nerve, 
Purklnje's,  £c. 


Fibrillation,  see  also  Auricular,  and 
Ventricular  Fibrillation. 

-  Causes  ,  Results,  Treatment  ,  55,62-3 

-  of  Heart,  Action  of  Cells  in,  during, 

52,  (fig.)  51. 

--  Excised,  stopped  byCamphor,316. 
Fibroid  Degeneration  of  Heart. 
---  Bradycardia  in,  167. 
---  Causes,  Results,  152,  153,  160-1. 
Fibrosis  of  Arterioles,  in  relation  to 

Chronic    Interstitial    Neph- 

ritis, 92. 

-  Arterio-capillary,      see       Arterio- 

sclerosis. 
Fibrous  Patch  on  Cardiac  Wall  from 

Partial   Block   of  Coronary 

Artery,  153. 

Pick's  Spring  Manometer,  96. 
Fifth  Nerve,  Nasal  Branches,  Stimu- 

lation, for  Relief  of  Fain  tness, 

422. 
Finger  Exercises,  during  Rest  Treat- 

ment, 239-40. 
Finger-pressure  Measurement  of  Hu- 

man   Blood-pressure,  100-1, 

114,  119-20,  128-9. 
Fingers,  and  other  Extremities,  as 

affected    by  Raynaud's  Dis- 

ease, 197. 
First  Sound  of  Heart,  How  Caused, 

76-7,  where  Loudest,  77. 
---  Alteration  in,  to  be  heeded  in 

course  of  Rheumatic  Fever, 

&c.,367. 
Fish  in  Diet  of  Convalescents  from 

Acute  Heart'  Disease,  379. 

-  in  Water,  analogy  to,  13. 
Flannel,    Bag,    and    layers    of,    for 

Poultices,  256-7. 

-  Covering    to    Ice-bag,    in    Endo- 

carditis, 376. 

-  Nightgowns  for  Rheumatic  Fever 

Patients,  370. 

Flatulence,  Causes,  Locations,  Re- 
sults, Treatment,  176,  224 
225-9,  238.  811,  355  et  sqq. 
361,  362,  372,  374,  379,  382 
385,  430-1,  (fig.)  226. 

-  Effect  of,  on  Heart,  176,  225-8,  874 

382,   (  fig.)   220,   in'  Angina 
418-9  ;  avoidance  of,  442,  443. 

-  -  Pulse,  438. 

Flatulence  -  provoking  Foods,  avoid- 
ance of,  in  Chronic  Heart 
Disease,  385. 

Flatulent  Distention  of  Stomach, 
Effect  on  Heart,  176,  225-8, 


2  K 


490 


INDEX 


Flow  of  Blood,  see  Circulation. 
Flowers,    Night-removal     of,    from 

Hick-rooms,  42C. 
Fluid,  at  Meals,  bad  for  Digestion, 865, 

Best  Taken  After,  374,  SS4. 

-  Nutrient,  used  in  Artificial  Circula- 

tion    through     Mammalian 

Heart,  273. 
Flushes   of  Heat,  177,    Treatment, 

449-50. 
Flushing  out  Stomach,   Importance 

of,  88G. 
Fly-fungus,  Active  Principle  of,  see 

Muscarine. 

Fceniculi,  Aqua,  as  Carminative,  300. 
Fomentation,   Warm,    to    Stimulate 

Feeble  Cardiac  Action,  268. 
Food(s),  see  Diet,  Fish,  Liquid,  Meat, 

Proprietary,  Solid,  £c. 

-  Effect  of,  on  Blood-pressure,  110. 

-  Fermentation  of  (see  u.lso  Fermenta- 

tion),^ Stomach, Death  from, 
how  Caused,  226-7,  (fig.)  226. 

-  Lack  of,  Cause  of  Feeble  Heart 

and  Pulse,  158. 

-  Manneic  of  Cooking  and   Serving, 

Importance  of,  385. 

-  Stimulating  Gastric  Digestion,  387. 

-  Warm,  to  Induce  Sleep,  235,  431. 
Fowls,  Fatty  Degeneration  in,  after 

Vagus-section,  160. 
Fresh-water  Hydra,  Neuro-muscular 

Cells  of,  28  et  sqq.,  (Jigs.)  29. 
Frog,  Accelerating  Fibres  of,  in  Vagus 

alone,  71. 

-  Amputated  Limb  of,  Arterial  Con- 

striction and  Dilatation  in,  8. 

-  Arterioles  of,  Dilatation  in,  Caused 

by  Local  Irritation,  87. 

-  Circulation  in. 

--Artificial,  26,  Lud wig's  Method, 
271-2. 

Drug  Action  during.  Investi- 
gated, 268. 

Nutrients  in,  Action  of,  285. 

-  -  Natural,  Effect  on,  of  Heat  and 

Cold,  93. 

-  Heart  of 

-  -  Action  on,  of 
Aconite,  329. 

Atropine,  281,  Seasonal  Differ- 

ence  in,  282. 

Camphor,  62,  816. 

Digitalis,  296-7,  303. 

Drugs,    Investigation    of,    267 

et  sqq. 
Muscarine,     as     Affected     by 

Inurement,  280. 


Frog,  Heart  of,  Action  on,  of  (cont.) 

Nicotine,  828,  824. 

Nutrients,  Experiments   with, 

284-5. 
--Apex  of,  Effect  on,  of  Stimuli, 

29-30,  85,  221. 

-  -  Diagram  of  (fig.),  26. 

-  -  Extra  Systole  in,  Compensatory 

Pause  after,  46. 

-  -  Heart-block  in,  Oaskell's  Experi- 

ments, 31-2,  40,  58,  (fig.)  82. 
--Inhibitory    Ganglia,    in,    Stan- 
nius's     Experiments,     40-2, 
(figs.)  41. 

-  -  Movements  of,  25  et  *</'/• 

-  -  Muscular  Fibres  in,  of  Two  Kinds, 

Schmiedeberg's  Hypothesis 
on,  270,  cf.  86. 

—  Nerve  Fibres  of,  29  n. 

-  -  Refractory  Period  in,  44-6,  Stimu- 

lation during  (fig.),  43. 

-  -  Stannius's  Experiment  of  Liga- 

turing, 31,  40-2,  (figs.)  41. 

-  -  Stimulation,  Electrical,  of,  44-7, 

(Jigs.)  48,  45. 

—  Stimuli  in,  Conduction  of,  Origin 

or  Conversion  of,  27,  30. 

—  Stoppage  of,  by  Blow  on   Intes- 

tines, Goltz's  Experiments, 
178,  (fig.),  il>.  | 

-  -  Structure,  26-7. 

—  Venous  Sinus   of,  Effect  on,  of 

Electrical  Stimulation,  46-6, 

(fig.)  45. 
InhibitoryApparatus(probable) 

in,  42,  (fig.)  45. 
Pulsatile  Contraction  of,  21. 

-  -  Ventricle  of,  26 

Apparatus    for     Investigating 

Action  on,  of  Drugs,  Devised 
by  Kronecker,  Improved  by 
Williams,  269. 

-  -  Deductions  on,  from  Stannius's 
Experiments,  40-2. 

Different  Reactions   of   Inside 

and  Outside  of,  269-71. 

Refractory  Period  of,  44. 

-  Leg  of,  Sartorius  Muscle  of,  Excita- 

tion of  when  Motor  Nerves 
Inactive,  29. 

-  Lung  of,  Effect  on  Capillaries  of,  of 

Heat  and  Cold,  94. 

-  Lymph  Hearts  in,  14. 

-  Muscle  of 

—  Action  on,  of 

Aconitine,  as  Affected  by  Atro- 
pine, Seasonal  Difference  in, 
282. 


INDEX 


491 


Frog,  Muscle  of,  Action  on,  of  (cont.) 
•  -  Barium,  Counteracted  by  Beef 

Tea,  279. 
Veratrine,       Differing       with 

Temperatures,  282. 

-  -  Effects  on,  of  Cafifeiu,  Different 

Results  Obtained  by  Different 
Observers,  Reasons,  284. 

—  Local  Applications  to,  of  Poison, 
Action  of  Atropine  made  out 
by,  275. 

Functional  Cardiac  Diseases,  Treat- 
ment, 411  tt  sqq. 

Bibliography,  457  tt  sqq. 

-  -  Murmurs,  Causes  and  Indications 

of,  217. 

-  Motor    Disturbances,    Causation, 

186. 

-  Sensory  Phenomena,  185-6. 
Funnel  for  Oxygen  Administration, 

241. 

GAEBTNEB'S  Tonometer,  103,  (fig.)  104. 

Galbanum,  Pill  of,  as  Carminative, 
361. 

Gall-bladder,  Effect  on,  of  (a)  Pres- 
sure from  Without,  (6)  Dis- 
tention  from  Within,  186. 

Gallop  Rhythm  of  the  Heart,  Causes 
of,  and  Deductions  from, 
211-2. 

Galvanometer,  String,  of  Einthoven, 
Nature  and  Use  of,  139  &  n., 
140-1,  (fig.)  142. 

Games  and  Sports  for  Cardiac 
.patients,  Rules  on,  251-2. 

Ganglia  "(see  Bidder's,  <t  Remak's), 
and  Ganglionic  Cells,  Frog's 
Heart,  26-7. 

-  in  Frog's  Heart,  52-3, 35. 

-  -  Inhibitory,  324 ;  Stannius's  Ex- 

periments, 40-2,  (figs.)  41. 

-  in  Medusae,  34,  35. 

-  Peripheral,  Stimulated  by  Strych- 

nine, 317. 

Ganglion  Cells,  in  Auricle,  Inhibitory 
Action  of,  42. 

-  -  at  Heart  Nodes,  56. 
Gangrene,  Induced  by  Severe  Forms 

of  Raynaud's  Disease,  198. 

-  Senile,  Causes,  204. 

Gases,  in  Stomach  and  Intestines 
(see  also  Flatulence),  358 ;  the 
Chief,  355,  357 ;  how  Dimin- 
ished and  Expelled,  360,  374. 

Gaskell's  Clamp,  Effect  of  Applying 
to  Frog's  Heart,  31-2,  40,  58, 


Gastric  Acidity,  Alkalis  for,  431. 

-  Antiseptics,  355,  356. 

-  Catarrh,  and  Dyspepsia,  from  Post- 

nasal  Catarrh,  390-1. 
-Digestion,  Process  of,  Stimulating 
Adjuncts  to,  386  et  sqq. 

-  -  Urine  Secreted   at    Height    of, 

Nature  of,  391. 

-Distention,  Effect  on  Heart's 
Action,  73,  176,  225  et  sqq., 
(figs.)  226,  358. 

-  Disturbance,  Shock  from,  179-80. 

-  Irritation,  in  Digitalis  Poisoning, 

303-4. 

-  Juice,  Normal,  Antiseptic  Action 

of,  how  Impeded,  355;  Pyloric 
Sensitiveness  to,  388. 

-  Mucous  Membrane,  Sedative  Treat- 

ment of,  420. 

-  Ulcer,  and  Abdominal  Pulsation, 

177. 

-  -  ReflexStimulationfrom.of  Vagus, 

Brady  cardia  from,  167. 
Gastrocnemius     Muscle,    in     Frog, 

Curves  of,  Normal,  and  after 

use  of  Barium  Chloride  and 

Liebig's  Extract  (fig.),  279. 
General  Paralysis,  Bradycardia  due 

to,  166. 
General  Principles  of  Treatment  in 

Chronic  Heart  Disease,  380 

et  sqq. 

Bibliography,  398  et  sqq. 

Genito-urinary  Tract,  Action  on,  of 

Digitalis,  308. 
Gibson's    Recording   Sphygmomano- 

meter,  115. 
Giddiness  (see  also  Vertigo),  Causes, 

Incidence,    and    Treatment, 

200-1 , 219,327, 400-1, 407,423-4. 
Ginger,  Tincture  of,  as  Carminative, 

361. 

Glands,  see  under  Names. 
Glandular  Activity,  Interaction  of, 

391  et  sqq. ,  396. 

-  Control,  of  Normal  Heart  Tone,289. 

-  Extracts  (see  also  under  Names), 

Medicinal  Uses  of,  381. 
Glebe    Granulated    Cane   Sugar,    in 

Treatment  of  Failing  Heart, 

287. 

Glucose,  as  Cardiac  Nutrient,  287. 
Glutens  maximus  Muscle,  Function 

of,  12. 
Glycogen,  Production  and  Storage  of, 

395. 
Goitre,  Exophthalmic,  Pulse-rate  in, 

105. 


492 


INDEX 


Graduated  Exercise,  in  After-cure 
for  Nauheim  Treatment, 
249-50;  in  Oertel's  Treat- 
ment, 260-1. 

-  -  Effect,  on  Pulse,  157  (fig.)  ib.  ; 

during  Rest  Treatment, 
289-40,  (fig.)  240. 

Graves's  Disease  (see  also  Exoph- 
thalmic Goitre),  Angina-like 
Pain  in,  193. 

-  Palpitation  in,  Associated  Condi- 

tions, Causes,  Treatment, 
415-6. 

Grey  Powder,  as  Intestinal  Disinfect- 
ant, 859. 

Grief,  Sense  of  Oppression  from, 
Cause,  probable,  of,  Author's 
Experience  and  Czermak's 
Experimental  do.,  186-7  ikn. 

-  Worry  and  Anxiety,  Effect  of,  on 

Circulation,  159-60. 
Guarana,  as  Nerve-Stimulant,  818. 
Guinea-pigs,    Fatal   Effects    on,    of 

Barium,  Retarded  by  Cold, 

288. 
Guipsine,  as   Vaso-dilator,   340  ;   in 

Angina  Pectoris,  444. 
Gums,  Irritation  of,  Cause  of  Head- 

ache.   447;     Painting    with 

Tincture  of  Iodine  in  Pyor- 

rhoea alveolaris.  888. 
Gustatory  Centre,  Disturbance  of,  by 

Arterial  Contraction,  186. 
Gymnastic  Exercises,  Overstrain  in, 

False  Angina  from,  193. 


iNURiA,    Raynaud's  Dis- 
ease associated  with,  197. 
Hsemoptysis,  Causes  of,  222. 

-  Dichrotic  Pulse  in,  131. 
Haemorrhage,  Cerebral,  Causes  Re- 

sults, 145  ;  Treatment,  455-6. 

-  Post-partum,  Pituitrin  in,  29,  819. 

-  Severe,  Blood-pressure  Low  in,  181. 

-  in  Typhoid  Fever,  Pituitrin  for,819. 
Hales,  Rev.  Stephen,  Inventor  of  the 

Manometer,  15,  146. 
Hamamelis,  Ointment,  or  Supposi- 

tory of,  for  Pruritus  Ani,  428, 

429. 
Hands,  Warm  Applications  to,  Action 

of,  in  Relief  of  Faintness,  423. 
Harvey,  and  the  Case  of  Lord  Mont- 

gomery, 186. 

-  Discovery  by,  of  the  Circulation, 

2,8. 

-  cited    on    Regulating    Action    of 

Arteries,  7,  8,  20. 


Head,  Lower  than  Body,  Pulse-rate 
with,  162. 

-  Movements   of,    Inducing    Giddi- 

ness in  Labyrinthine  Vertigo, 
428. 

-  Stroking,  and  Hair-brushing,  for 

Insomnia,  429. 

-  Throbbing  in,  177. 

Headache  (tee  also  Migraine),  Causes 
and  Treatment,  445  et  sqq. 

-  after       Cerebral       Haemorrhage, 

Leeches  for,  456. 

-  Common  in  Heart  Disease,  with 

High  Tension,  188. 

-  of  Menstrual    Period,    Pathology 

and  Treatment,  449. 

-  Severe,  Leeches  for,  257. 
"Headache   in    the   Stomach,"    see 

Angina  Abdominis. 

Healthy  Persons,  Functional  Cardiac 
Murmurs  in,  215-6. 

Heart,  see  also  Apex,  Artificial  Cir- 
culation, Auricles,  Auricular 
Base,  Cardiac,  Dog's  Heart, 
Embryonic  Heart,  Fatty, 
Fibroid,  &  Parenchymatous 
Degeneration,  Frog's  Heart, 
Hypertrophy,  Invertebrate, 
Lymph  Hearts,  Palpitation, 
Pulse,  Rabbit's,  Sheep's  & 
Turtle's  Heart,  Valves,  Ven- 
tricles, Ventricular,  Verte- 
brate, <Cc. 

-  Accelerating,  Nerves  of.  Functions 

of,  71-2. 

-  Action  of,  Arrest  of,  in  Systole  by 

Perfusion  with  Calcium,  285. 

-  -  Co-ordination    of,    with    Blood- 

pressure,    How  Maintained, 

ir<en.,i8. 

with    that    of   other  Vessels, 

Nerve-control  of,  52-3. 

-  Action  on,  of 

-  -  Aconite,  829. 

-  -  Adrenalin,  276,  315. 

-  -  Alcohol,  835. 

-  -  Alkaline  Bases,  834. 

-  -  Ascites,  225-8. 

-  -  Caffeine,  817-8,  488. 

-  -  Camphor,  488. 

-  -  Chloral,  484. 

-  -  Cocaine,  829. 

-  -  Coughing,  229. 

-  -  Digitalin,  438. 

-  -  Digitalis,  117,295,296,299,307,488. 
Drawbacks,  812. 

Nullified  by  High  Bodily  Tem- 
perature, 281. 


INDEX 


493 


Heart,  Action  on,  of  Digitalis  (cant.) 
in  Toxic  Strength,  Stages,  &c., 

in,  301-5. 
—  Disease    of    Suprarenal    Gland, 

according  to  Portion  Affected , 

289-90. 

-  -  Emotion ,  158. 

-  -  Flatulence,  and  Treatment,  176, 

225  et  sqq.,  (figs.)  226,  358. 
--Heat  and  Cold,  92-4. 

-  -  Inhalations  of  Oxygen,  &c.,  240, 

260,  How  Best  Given,  and  in 
What  Combinations,  241-3, 
(figs-)  242-3. 

-  -  Inorganic  Salts,  285-6. 

-  -  Irritation  of  Vagus    Trunk  (see 

also  Vagus,  below),  267. 

-  -  Massage  and   Graduated  Move- 

ments, 157-8,  236  et  sqq., 
(figs.)  157,  240. 

-  -  Massage  and  Best,  236-8. 

-  -  M  uscarine,  278. 

-  -  Nauheim  Treatment,  249. 

-  -  Nicotine,  315,  323,  324. 

-  -  Nutrients,  284. 

-  -  Pituitary  Gland,  289. 

-  -  Plasters  over,  262-3,  (fig.)  263. 

-  -  Strophanthus,  155-6, 217, 812, 813, 

407,  409,  413,  418,  483,  488, 
440,  445. 

-  -  Strychnine,  316-7,  438. 

-  -  Vagus,  65  et  sqq.,  178,  (fig.)  300. 

-  Activity  of,  Nutrition  Dependent 

on,  155. 

-  Afferent   and  Sensory  Nerves  of, 

Functions,  64-5. 

-  after  Death,  in  Relation  to  Section 

or  Stimulation  of  Vagi,  70  &  n. 

-  in  Angina  Pec  tor  is,  189-90. 

-  Arrest  of,  in  Diastole,  from  Excess 

of  Potassium,  and  Stimula- 
tion of  Vagus,  286. 

-  -  ill  Systole  from  Digitalis  poison- 

ing, 296. 

-  Auricle  as  Motor  of  Circulation,  25. 

-  Block  Fibres  in,  28,  81. 

-  and  Blood-vessels, 

-  -  Action  on,  of 
Alcohol,  355. 

Alkaline  Bases, Different  Effects 

in,  334. 
Digitalis \(q.  v.),  296, 807, 312,483. 

-  -  Drugs  Acting  Indirectly  upon,  284. 
• Nicotine,  315,  323. 

-  Characteristics  of,  55-6. 

-  Comparison  between,  and  a  Medusa, 

Romanes's  Experiments,  33 
et  $qq. 


Heart  (cont.) 

-  Conduction  of  Stimuli  in,  by  Nerves 

as  well  as  Muscle,  46-7,  (fig.) 
45. 

-  Contractile    Power   of,   on    What 

Dependent,  150-1,  Increased 
by  Cardiac  Tonics,  294. 

-  Contraction  of,  21,  55,  Drugs  Caus- 

ing (see   Caffeine,    Digitalis, 
do.,  &  Vaao-constrictors),  298. 

—  Mode  of,  Instruments  for  Inves- 

tigating, 123-6. 

-  -  from  Suprarenal  Extract,  190. 

-  Dilatation,  Active,  of,  55. 

-  -  Diminished  by  Nauheim  Treat- 

ment, Author's  Personal  Ob- 
servations on,  249. 

-  -  in  Endocarditis,  Treatment,  376. 

—  Feebleness  due  to,  158. 

-  Dilated  and  Contracted,  showing 

Action  of  Valves  (fig.),  75. 

-  -  and       Failing       Compensation, 

Symptoms,  219. 

—  Functional       Murmurs       with, 

Rationale  of,  75,  215. 

-  Displacement  or  Tilting  of,  by 

—  Stomach  Distention  and  Flatu- 

lence, Results,    176,    225   et 
qq.,    230;    Treatment,    289, 


-  Tight-lacing,  &c.,  227-8. 

-  Diseases  of,  see  Heart  Disease,  below  . 

-  Examination  of,  by  X-Rays,  138. 

-  Excised,  Exposed,  Isolated. 

-  -  Effect  on,  of  Lack  of  Oxygen  and 

Accumulation  of  CO2,  151. 

-  -  Experiments  on,  as  to  Action  of 

Drugs,  344. 

-  -  Extra  Systoles  in,  how  Induced, 

171-2. 

-  -  Fibrillation     of,     Stopped     by 

Camphor,  316. 

-  -  Glucose  as  Nutrient  for,  287. 

-  -  Sound     Made,     when     Beating 

against  Board,  76. 

-  Extrinsic  Nerves   of,  63    et   tqq. 


-  Failing,  Sugar  Treatment  of,  253, 

287. 

-  Failure,  Senile,  How  to  Avert,  452 

-  Feeble,  Heat  Beneficial  to,  263. 

-  Feebleness  of  (see  also  Weakness 

bel»w),  Effect  of,  on 

-  -  Nutrition  of 

---  Blood-vessels,  157-8,  (fig.)  157. 
---  Itself,  154-6. 

-  Gallop    Rhythm    of,  Causes    and 

Indications,  211-2. 


494 


INDEX 


Heart  (co»t.) 

-  Health  of,  on  What  Dependent,  880. 

-  Inflammation     of,    Causes,     and 

Forms,  151-2. 

-  Inhibitory      Centre      for,     How 

Functioning,  67-8 ;  Excessive 
Action  of,  and  Bradycardia, 
166-7. 

-  Intrinsic  Nerves  of,  52, 64,  (fig.)  85. 

-  Ligatured,  Slowing  or  Stoppage  of, 

Prevented  by  Strychnine,  31 7. 

-  Movements  of,  25-6  et  sqq. 

-  a  Muscle,  Nuirition-laws  of,  897. 

-  Muscular     Cells     of,     Transverse 

Contraction  of,  as  Affecting 
Cardiac  Poisons,  270-1. 

-  -  Fibres   of,  60-2,    Action   on,  of 

Digitalis,  298. 

-  Muscular  Structure,  50-2. 

-  Nerves  of,  68-73. 

-  Nodes  of  (see  A.V.  &  8. A.),  Accel- 

erator Nerves  probably  act- 
ing through,  72. 

-  -  Stimuli  to,  Origin  of,  56. 

-  Kceud   Vital  of,  Experiments  on, 

of  Kronecker  and  Schmey, 
61-2,  (flg.)  62. 

-  Normal    Position    of,   relative    to 

Stomach,  225-6,  (fig.)  226. 

-  Nutrition  of,  150-1,  154-5. 

-  -  Best  Nutrient  of,  284. 

-  Organic   Diseases    of,    see    under 

Diseases. 

-  Pacemaker  of  (S.A.  Node),  58,  72. 

-  Perfusion  of,  as  affecting  Inhibi- 

tory Power  of  Vagus,  71. 

-  Peripheral   Nervous    System    of, 

Action  on,  of  Caffeine  and 
other  Purin  Bodies,  317-8. 

-  Physiology  of  General,  25  et  sqq. 

-  -  Bibliography,  47-9. 

-  -  Mammalian,  50. 

-  -  Bibliography,  78-83. 

-  Plasters  over,  262-3,  (fig.)  268. 

-  Protoplasmic  Connective  Cells,  58. 

-  Purkinje's  Fibres  in,  28. 

-  Quickening  of,  Mechanism  of,  72-3. 

-  Refractory  period  of,  4,  6,  14,  42 

et  sqq.,  271. 

-  Rest  or  Sleep  of,  4-6,  14,  44,  Effect 

on,  of  Massage,  238. 

-  Rhythm,  Effect  on,  of  Aconite,  829. 

-  Right     Side,     Course     of    Blood 

from,  77. 

-  -  Engorged  Conditions  of,  Benefit 

in,  of  Bleeding,  258-9. 

-  -  Extra  Tension    in,    in    Recum- 

bency, 234. 


Heart,  Right  Side,  (cont.) 

-  -  Feebleness  of,  as  Cause  of  Cardiac 

Asthma,  444-5. 

-  Self  Massage  of 

-  -  Action  on,  of 
Digitalis,  808. 

Massage,  Exercises,  and  Rest, 

288,  240,  (fig.) 240. 
Oxygen  Inhalations,  241,  (figs.) 

242,  243. 

-  -  in  Relation  to  Nutrition,  154-5. 

-  Sensitiveness  of,  186-7. 

-  Skiagrams  of,  How  Obtained,  188-9. 

-  Slowing  of,  Mechanism  of,  72-8. 

-  -  Methods  of,  by  Combined  Rest 

and  Massage,  288. 

-  -  by  Stimulation  of  Venous  Sinus, 

324. 

-  Sounds  of,  see  Cardiac  Murmurs, 

and  Sounds  of  the  Heart. 

-  Stimulation  of,  Effects,  56. 

-  -  Methods,  90,  415,  422-3. 

-  Stoppage  of  (see  also  Arrest,  above), 

by,  or  from 

-  -  Blocking  of  Coronary  Arteries, 

162-4. 

-  -  Imperfect  Anaesthesia,  178, 179. 

-  -  Puncture  of  Nceud  Vital,  61-2. 

-  -  Reflex  Stimulation  of  Vagus,  72-3. 

-  -  Various  Causes,  177  et  sqq.,  Val- 

salva's  Experiment,  172,  228. 
-  When  Caused  by  Digitalis,  313. 

-  Strength  of,  in  Relation  to 
Diastolic  Pressure,  118. 

Resistance,    How    Estimated, 

115  et  sqq. 

-  -  Shown  by  Sphygmograph,  129-82, 

138. 

-  Suction  Action  of,  9,  154-5,  (figs.) 

155. 

-  Tone  in,  Nature  and  Limits  of, 

288-9  ;  How  Maintained,  289. 

-  Two  Sides  of,  Affections  of,  161. 

-  Valves  of  (see  also  under  Names), 

Action  of,  73  et  sqq.,  Ap- 
paratus for  Demonstrating 
(fig.),  74. 

-  -  Insufficiency  of,  75,  (figs.)  75. 

-  Walls    of,    Hypertrophied,    First 

Sound  with,  212,  213. 

-  Weakness  of,  from 

-  -  Block  of  Coronary  Arteries,  153. 
'-  -  Diphtheria,  160-1. 

-  -  Various    Causes,     Results     on 

Pulse,  158 

-  Work  of,  Involved  in 

-  -  Getting  into  Bed,  238. 

-  -  Going  Upstairs,  233,  407. 


INDEX 


495 


Heart-block.  Bigeminal  Pulse  from, 
169-70,  (fig.)  170. 

-  Bradycardia  due  to,  167. 

-  Causes,  32,  86,  59-61,  68-70,   306, 
*  421,  (fa.)  69. 

-  Condition   like,    induced    by    Er- 

langer's  Experiments,  169. 

-  Definite,  Prognosis,  437. 

-  Diagnosis,  methods,  137,  188. 

-  Functional,  60-1. 

-  GaskeH's  Experiments  on,  in  Frog's 

Heart,  Sl-2,  40,  58,  (figs.)  32. 

-  Indications  of,  on  Sphygmograms 

of  Venous  Pulse,  137. 

-  Opposite  Action  of  Vagus  as  to,  68, 

69-70,  (figs.)  36,  69. 

-  as    Part  Cause   of  Stokes- Adams 

Syndrome,  168, 169. 

-  Tendency  of  Digitalis  to  produce, 

421. 

Heart    Disease(s),    see    also    under 
Names. 

-  Acute,  see  also  Rheumatism,  Acute. 

—  Attention  concentrated    on  the 

Affected  Organ,  380. 

-  -  Causes,  367-8. 

-  -  Clothing  for  Patients,  370. 

—  Convalescence  from,  Treatment, 

879. 

-  -  Early  Signs  to  be  watched  for, 

867. 

-  -  Use  of  Thermometer,  367-8. 

-  -  Flatulence  in,  How  Avoided  or 

Dealt  with,  374. 

-  -  Medicines  for,  374-5. 

-  -  Rest  in,  368,  369. 

-  -  Sponging  of  Patients,  370-1. 

-  -  Treatment,  366  tt  sqq. 

-  Adalin  as  Suitable  Hypnotic  in, 436. 

-  Age-Incidence  of  Mortality  in,  202. 

-  Chronic,    General    Principles    of 

Treatment  in,  380  et  sqq. 

-  -  Exercise  in,  155,  367. 

-  Indirect  Treatment  in,  882. 

-  Irregular  Action  in,  Causes  other 

than  in  the  Organ  itself,  882. 

-  Points  to  heed,  Treatment,  366-7. 

-  -  Valvular,  Treatment,  402  et  iqq. 

-  Functional  Treatment,  411,  et  sqq. 

-  Insomnia  in,  Form  of  Opium  or 

Morphine  in,  480. 

-  Nauheim  Treatment  for,  243. 

-  Organic,  210  et  sqq. 

-  -  Bibliography,  230-1. 

-  Other  Forms  of,  228-9. 

-  Recovery  in,  How  to  Aid,  366-7. 

-  Surgical  Treatment  of,  408. 

-  Vicious  Circle  of,  229. 


Heat,  see  also  Hot,  Warm,  <fc  Warmth. 

-  Applications  of,  Locations  for,  in 

-  -  Cerebral  Haemorrhage,  456. 

-  -  Headache,  448. 

-  -  Heart  Feebleness,  263. 

-  Causing     Insomnia,      Treatment, 

427-8. 

-  Flushes  of,  177,  Treatment,  449-50. 
Heat   and    Cold,    see  also   Cold,    & 

Temperature. 

-  Action  of,  Sedative  and  Stimulant, 

263     . 

-  -  Ettect  of,  on 

Capillaries,  132,  (fig.)  ib. 

Pulmonary,  94. 

Circulation,  92  et  sqq.,  258-7. 

Heart,  92-4. 

Pulse-rate,  6,  162-3. 

Splanchnic      and      Intestinal 

Blood-vessels,  20. 
Hedonal,  as  Hypnotic,  435. 
Helleborein,    Action    of,    on    Frog's 

Ventricle.  270. 

Helleborusniger  (Christmas  rose),3]  1. 
Hemianopsia,  Causes,  185. 
Hemiplegia,  Causes,  145,  186,  202. 

-  Transient,      Raynaud's      Disease 

associated  with,  197. 

Hemisiue  Tabloid,  in  Graves's  Dis- 
ease, 416. 

Hepatitis,  Leeches  over  Liver  to 
Relieve,  258. 

High  Tension  (see  also  Arterial  Ten- 
sion), in  Aorta,  Accentuation 
of  Second  Sound  due  to,  210-1. 

Hill  and  Barnard's  Form  of  Sphygmo- 
manometer,  104. 

Hill's  Sphygmomanometer,  102. 

Hippurates,  of  Ammonium,  in  Senile 
High  Tension,  454. 

-  of   Ammonium    and    Sodium,    in 

Angina,  443. 

-  as  Vaso-dilators,   330,  Action  on 

Kidneys,  340. 
Hippuric  Acid,  Conversion  of,  into 

Benzoic  Acid,  91<6». 
Hirschfelder's  Recording   Sphygmo- 

mauometer,  115. 
Hirudin  preventing  Clotting,  96. 
His,    Bundle   of,  57,    Clamping   of, 

Heart-block  due  to,  59. 

-  -  Lesions    with    Heart-block,,  as 

Cause     of      Stokes  -  Adams 

Syndrome,  168. 
Hoarseness,  from  Excessive  Smoking, 

327. 
Hollow  Muscular  Organs,  Cause  of 

Pain  in,  186. 


496 


INDEX 


Honey,  in  Treatment  of  Failing 
Heart,  Drawbacks,  287. 

Hormones,  Nature  and  Functions  of, 
898. 

Horse,  Blood-pressure, Average  in,  96. 

Hot  Baths 

-  -  Air,  for  Cardiac  Pain,  257. 

-  -  Water,  Effects  of 

Dilation  ofVessels, from  putting 

Feet  into,  Author's  Ex- 
perience, 254. 

Palpitation  induced  by,415,428. 

-  Drinks,  in  Belief  of  Faintness,  422. 

-  Sponging   of   Anus,    in    Pruritus 

ani,  429. 

-  Water,  Digestive  Value  of,  Hints 

on  Taking,  385-6. 

-  -  Bag,  preferable  to  Stone  Bottle 

for  Warming  Cold  Feet,  &c., 
426,  a  Warning  on,  427. 

to  Stimulate  Feeble   Cardiac 

Action,  263. 

Huka-Smoking,  and.Inhalation,  325-6. 

Hiirthle's  Manometer,  96. 

Hyderabad  Chloroform  Commission, 
on  Tight-lacing,  227. 

Hydra,  Fresh-water,  Neuro-muscular 
Cells  in,  28-9,  (figs.)  29. 

Hydrocathartics,  Nature  and  Uses, 
352-3. 

Hydrochloric  Acid,  after  Meals  to 
Aid  Digestion,  387-8. 

Hydrocyanic  Acid,  Dilute,  as  Local 
Gastric  Sedative  in  Paroxys- 
mal Tachycardia,  419 

Hydrogen  Peroxide,  as  Mouth-wash, 
383,  426. 

Hydrostatic  Pressure  as  affecting 
Blood-flow  in  Veins,  9. 

Hydroxylamine,  as  Vaso-dilator,  338, 
389. 

Hyoscyamine,  Effects  of,  on  Ventri- 
cular Contraction,  differing 
with  Temperature,  282. 

Hyperdichrotic  Pulse,  Cause,  181. 

Hypertrophy,Cardiac,fromAtheroma 
of  Coronary  Artery,  153-4. 

-  -  Good  and  Bad  Sides  of,  452. 

-  -  in   Rabbits    with    Experimental 

Aortic  Regurgitation,  406. 

-  -  X-Ray  Diagnosis,  188. 

-  -  of  Ventricular  Walls  as  affecting 

First  Sound.  212-3. 
Hypnotics,    Three   Classes,  Action, 

433  et  sqq. 
Hypodermic  Injections  of 

-  -  Morphine,  in    Cardiac  Asthma, 

445. 


Hypodermic  Iig'ections  of  (coat.) 

-  -  Morphine  (font.) 

in  Endocarditis  Pain,  376. 

-  -  Strychnine,  in  Cerebral  Throm- 

bosis, 456 ;  in  Cardiac  Failure    e 
in  Acute  Rheumatism,  875. 

Hypoxanthine,  288. 

Hysteria,  False  Angina  in,  193. 


ICE,  and  Iced  Water,  in  Faintness, 
423;  in  Paroxysmal  Tachy- 
cardia, 418. 

Ice-bag  over  Heart  as  Sedative,  268, 
376,  413. 

Ichthyol,  for  Chronic  Urticaria,  450-1. 

Imperial  Drink,  in  Rheumatic  Fever, 
373. 

Inaudibility  of  First  Heart  Sound, 
Prognosis,  212. 

Incision,  for  Pericardial  Effusion,  377. 

Incompetence,  tee  Aortic  d  Mitral. 

-  Secondary,  Functional,  219,  228. 
India-rubber   Bag   laid   over  moist 

Flannel,    as    Substitute    for 

Poultice,  257. 
Indians,  Blood-pressure  maxima  in, 

110. 
Indigo  Carmine,  with  Caffeine,  Action 

of,  Deductions  from,  349. 
Infective  Diseases,  Cardiac  Weakness 

from,  Bradycardia  associated 

with,  167,  form  of,  168. 
Fatty  Degeneration  in,   151, 

152,  153,  160, 161. 
Gallop    Rhythm,    indicative 

of,  212. 
Inflammation,  Chronic,  Bradycardia 

from,  166. 

-  of  Heart,  Endocardium,  and  Peri- 

cardium, Causes  and  Forms, 
151-2. 

-  Local ,  Reduction  of,  by 

-  -  Aconite,  253. 

-  -  Heat  and  Cold,  253-7. 

Hot  Air  Bath, -257. 

Poultices,  255-7. 

-  of    Mitral     Valves,    Causes    and 

Effects,  220. 

-  of  Nasal  Antra,  or  Sinuses,  Head- 

ache from,  447 

-  in  Pericarditis,  Blisters  for,  263. 

-  Repair   of   Tissues,    the   aim    of, 

451-2. 
Inflammatory    Processes,  Effect   of, 

on  Valvular  Orifices,  215. 
Influenza,  Blood-pressure  Low  after, 

181. 


INDEX 


497 


Influenza  (cont.) 

-  Bradycardia  after,  167,  168,  Treat- 

ment, 420-1. 

-  Heart  Disease  due  to,  368-9. 
Influenza    Bacillus,    Effect    of,    on 

Myocardium  and.  on  Vagus, 
152. 

Inhalation(s)  of  Ammonia  or  Chloro- 
form, Effect  on  Rabbit's 
Heart,  73. 

-  of  Oxygen,  Effect  on   Heart,  240, 

260,  How  Best  Given,  240  et 
sqq.,  (Jigs.)  242,  243. 

-  in    Tobacco-smoking,    Objections 

to,  325-0. 
Inhibition,  38. 

-  in  Frog's  Heart,  Action  of  Vagus, 

39-40. 

-  -  Apparatus  for,  26,  324. 

Stannius's     Experiments     on, 

40-2,  Author's  Diagrams 
illustrating  (figs.),  41. 

-  in  Medusae,  39.  • 

-  in  Turtle's  Heart,  39. 
Inhibitory  Centre  in  Medulla,  Action 

of,  on  Pulse-rate,  161-2. 

-  Fibres  of  Vagus,  Functions  of,  64, 

how  Exercised,  66  et  sqq. ; 
Effect  of  Stimulating,  324; 
Experimental  Paralysis  of, 
Results,  71-2. 

-  Nerves  of  Heart  (see  also  Vagus), 

Over-action  of,  Results,  64, 
158. 

-  -  Reflex  Stimulation  of,  72-3. 
Inotrope,  56. 

Insomnia,  Causes  and  Theory  of,  200, 
363-4,  424  et  sqq. ;  Conditions 
associated  with,  364,  416 ; 
Treatment  and  Diet,  255, 
364.  424  et  sqq. 

Inspiration,  Deep,  Action  of,  on 
Vagus,  419. 

-  Suction,  exerted  by,  Action  of,  on 

Circulation,  9. 

Instruments  for  Estimation  of  Blood- 
pressure,  15,  16,  101  et  sqq., 
114-5. 

Intercostal  Neuralgia,  Cardiac  Pain 
from,  440-1. 

Intermission  of  Heart  from  Gastric 
Irritation,  78. 

Intermittent  and  Irregular  Pulse 
(see  also  Dichrotic,  <Cc.),  169, 
437. 

Intestinal  Antiseptics  and  Disin- 
fectant!", Uses,  359-60, 
450-1. 


Intestinal  Blood-vessels  and  Circula- 
tion, Action  on,  of 

-  -  Cold  and  Heat,  20. 

-  -  Digitalis,  311,  &  Congeners, 334-5. 

-  Congestion,  Diminished  by  Massage 

and  Rest,  238. 

Intestinal  Contraction,  induced  by 
Pituitrin,  319. 

-  Digestion,  Process  of,  393. 

-  Dilatation,  or  Distention,  Action 

of,  on  Vagus,  438;  Asafoetida 
Enema  in,  361. 

-  Flatulence   (see   also   Flatulence), 

Carminatives  for,  361. 

-  Gases,  360,  374,  the  Chief,  355,  357. 

-  Glands,  Digestive  Fluid  from,  392  ; 

Hormones  of,  393. 

-  Inhibition,  by  Adrenalin,  815. 
Intestines,  Blow  on,  Heart  Stoppage 

from,  178,  (fig.)  ib. 

-  Effect  on,  of  Disordered  Circula- 

tion, 229. 

-  -  of  External  Pressure,  and    In- 

ternal Distention,  186. 

-  Muscular    Wall    of,    Paresis    of, 

Action  on,  of  Pituitrin,  362. 

-  Parts    of,    acted    on    by    Hydro- 

cathartics,  353. 

-  Reflex  Stimulation  from,  of  Vagus, 

Effects  on  Heart,  73. 
Intracranial   Pressure,   Bradycardia 

from,  166. 

Intra-Muscular  Administration  of 
Guipsine,  in  Angina  Pectoris, 

444. 
Pituitrin,  Conditions  in  which 

Useful,  319,  862. 
Intrinsic  Nerves  of  Heart,  52  et  sqq., 

(fig.)  85. 

Action  on,  of  Digitalis,  307. 

-  -  Functions  of,  in 

Epicardium,  52-4. 

Pericardium,  64-5. 

Inurement,  as  affecting  Drug-action, 

273,  279-80. 
Invertebrates,    Hearts    of,    without 

Ganglion  Cells,  Action  on,  of 

Vagus,  66. 

Inverted  Sphygmograins,  135,  (fig.)  ib. 
Involuntary  Muscles,  Action  on,  of 

Atropine,  Curare,  Nicotine, 

&c.,  274-5. 

-  -  Tone  in,  288-9. 
Iodide  of 

-  Ammonium  in  Angina  Pectoris, 444. 

-  Ethyl,     in    Angina,    or    Cardiac 

Asthma,    241-3,    445,    (figs.) 
242,  243. 


498 


INDEX 


Iodide  of  (conf.) 

-  Potassium  in 

-  -  Aneurism  Pain,  455. 

-  -  Angina,  varying  tolerance  of, 

443-4. 
Cardiac  Asthma,  445. 

-  -  Carotid    Atheroma,      for     In- 

somnia, 432. 

-  -  Cerebral  Thrombosis  of  Syphil- 

itic Origin,  457. 
Pericardial  Effusion,  377. 

-  -  Stokes- Adams  Disease,  421. 

-  Use  of,  Drawbacks  to,  340-1. 

-  Sodium,  in  Angina  Pectoris,  444 ; 

Use  of.  Drawbacks  to,  340-1. 
Iodides,  in  Belief  of  Headache,  448. 

-  Organic  Compounds  of,  in  Angina 

Pectoris,  444. 

-  in    Senile    Conditions    of    Blood- 

vessels, Steady  use  of,  453. 

-  Some  Effects  of,  842. 

-  in  Syphilitic  Heart-block,  437. 
Iodine,  Tincture  of,  Painting  on,  &c. 

-  -  Anus,  for  Pruritus  ani,  430. 

-  -  Gums,  for  Pyorrhoea  alveolaris, 

383. 

-  -  Tonsils,  as  Antiseptic,  883. 
lodoglidine,  in  Angina,  444. 
lodoprotein,  in  Angina,  444. 
lohydrin,  in  Angina,  444. 

Ionic  Medication  for  Cardiac  Pain, 

877,  441. 

lothion,  in  Angina,  444. 
Ipecacuanha,  with  Opium,  in  Dover's 

Powder,  864. 
Iron,  in  Apex-pain,  in  Women,  188. 

-  as    Tonic     for     Bradycardia     of 

Fever  Convalescence,  421. 

-  -  and  Iron  and  Arsenic  in  Anaemia 

Palpitation,  414. 

-  -  with       Pulvis      Mirabilis      for 

Anaemia,  440. 

-  Lactate,  Experiment  with,  340-1. 

-  Perchloride  of,  in  Flushes,  &c.,  of 

Menopause,  450. 

-  -  with  Quassia,  in  Cardiac  Pain, 

440. 
Irregular  Pulse,   tee  under  Names, 

and  Pulse. 
Irritation,  see  also  Stimulation. 

-  Local, EffectonArterioles,  observed 

by  Author  and  others,  87. 

-  -  Headache  from,  446. 

-  -  Soothing,  for  Insomnia,  429. 

-  of  Chorda  Tympani,  Effect  on  Sub- 

maxillary  Gland,  parallel  to, 
181. 

-  of  Dilating  Nerves,  Effects,  86,  87. 


Irritation  (conf.) 

-  of  Mucous  Membrane  of  Respira- 

tory    Passages,    Effect    on 
Vagus  and  Heart,  73. 

-  of  Nerves,  from  Severe  Pain,  Stop-    e 

page  of  Heart  from,  178. 

-  of  Pericardium,  Ventricular  Stand- 

still from,  78. 

-  of  Stomach,   Causes,   Treatment, 

856,  488. 

-  of  Vagus,  Roots,  Trunk,  and  Ends 

in  Heart,  Effect  on  Heart, 

17,  267. 
Isopropyl  Alcohol,  Experiment  with, 

on  Rabbit,  863. 
Itching,  Remedies  for,  in 

-  -  Pruritus  ani,  429-80. 

-  -  Urticaria,  45. 

JACQUET'S  Sphygmograph,  127. 

Jaundice,  Bradycardia  in,  Cause,  168. 

Joints,  Inflamed,  or  Painful,  in 
Rheumatic  Affections,  Band- 
ages, &c.,  for,  371,  Blisters 
for,  264,  868,  875. 

Jugular  Vein,  Pulsations  of,  186, 
(fig.)  137. 

Juniper,  Oil  of,  as  Diuretic,  360. 

Juniperi  and  Juniperi  Co.,  Spiritns, 
as  Carminative,  360. 

KEITH  and  Flack's  Node,  see  8.A. 
Node. 

Kidney  Disease,  Diffuse  Arterio- 
sclerosis in,  199;  Indicated 
by  Permanent  Accentuation 
of  Second  Sound,  211. 

Kidneys,  see  aZso  Renal,  Urinary,  and 
Urine. 

-  Action  on,  of 

-  -  Benzoates,  840. 

-  -  Caffeine  and  other  Purin  Bodies, 

817-9. 

-  -  Digitalis,  308, 301, 805-10 ;  in  Peri- 

carditis, 877. 

-  -  Disordered  Circulation,  229. 

-  -  Diuretics,  348  et  tqq. 

-  -  Emotion,  or  Excitement,  158. 

-  -  Massage  and  Rest,  289. 

-  -  Opium,  When  Contra-indicated, 

365. 

-  -  Pituitary  Extract,  90,  319. 

-  -  Venous  Engorgement,  224-5. 

-  Arteries,  Blood-vessels,  and  Circu- 

lation of,  (fig.)  848. 

-  -  Drugs   (Diuretics,  &c.),    Acting 

on,  846  et  sqq. 


INDEX 


499 


Kidneys,  Arteries  (cont.) 

-  -  Excretion  of  Urine  as  Affected 

by,  346-8. 

—  Mechanism  Regulating  Blood 
Distribution  in,  347-8,  (fig.) 
348. 

-  Double  Function  of,  in  Relation 

to  Blood-pressure,  91-2. 

-  Glomernli  and  Tubules  of,  Func- 

tions  of,    in    Excretion    of 
Urine,  347. 

-  Macrophag  Attacks  on,  204,  (fig.) 

203. 

-  Wet     Cupping    over,    in     Acute 

Nephritis,  258. 

Kola,  as  Nerve  Stimulant,  318. 

Kronecker  and  Schmey's  Experi- 
ments on  the  JYteud  Vital  of 
the  Heart,  61-2,  (fig.)  62. 

Kronecker's  Sphygmograph,  127. 

Kymographs  (s««  also  Manometers, 
&c.),  Ludwig's,  1 5, 95,  (fig.)  16. 

LABYRINTHINE  Vertigo,  423. 
Lactate  of  Iron,  Experiment  with, 

340-1. 

Lactates,  as  Leucomaines,  363. 
Lactic   Acid    as    Leucomaine,   363 ; 

Retention  of,    in    Stomach, 

Results,  388. 
Lactic   Acid  Bacillus,  Function  of, 

858-9. 

Lactose,  Diuretic  Action  of,  253. 
Laudanum     (see    also    Opium),    as 

Narcotic,  277. 

-  with  Bicarbonate  of  Soda  in  Oral 

Affections,  447. 

Lavender,  Oil  and  Spirit  of,  Carmin- 
ative Uses  of,  860. 

Laxatives  to  Aid  Defecation,  879, 896. 
Lead,  Subacetate  of,  as  Ointment  for 

Pruritus  ani,  438. 
Lead-poisoning,   Bradycardia   from, 

166, 168. 

Leads  of  String  Galvanometer,  140-1. 
Leech-extract,  96. 
Leeches,  Applications  of,  Cases  for, 

275-8,  876,  456. 
Left  Side,  Lying  on,  Effect  on  the 

Heart,  176. 
Legs,    Exercises    for,    in    Nauheim 

Treatment,  245,  248. 

-  Raising  of,  as  affecting  Tension  in 

Vena  Cava,  284. 

-  Rotatory  Muscles  of,  as  Accessory 

to  Circulation,  12,  236-7. 

-  Tapping  of,  for  (Edema,  260. 
Leucocytes,  9. 


Leucomaines,  and  the  Alternation  of 

Sleep  and  Waking,  363. 
Leucorrhcea,    Apex-pain     associated 

with,  188,  Treatment,  440. 
Life,  Prolongation  of,  by  Attention  to 

State  of  Arteries,  202. 
Ligature,  &c.,  of  Auriculo- ventricular 

Groove,  Heart-block  due  to, 

59,  (figs.)  41. 
Ligaturing   Coronary  Arteries   (and 

Veins),  Results,  63, 132-3. 

-  Frog's  Heart,  Results,    31,    40-2, 

(figs.)  41. 

-  Portal  Vein  and  Aorta,  Results,  19. 
Light-waves,  Effect  of  Interference 

of,  Tait's  Experiment,  87. 
Lily     of    the    Valley    (Convallana 

majalis),  811. 
Limbs,  Blood  Withdrawn  from,  by 

Brain  in  Activity,  180. 

-  Fasciae  of,  Action  of,  on  Venous 

Circulation,  11-12,  286-7. 

-  Frog's,  Amputated,  Arterial  Con- 

traction and  Dilatation  in,  8. 

-  Reflexes  in,  Caused  by  Extrinsic 

Afferent  Nerves,  65. 
Lime,  Dilute,  Action  on  Heart,  285. 
Liniment  of  Ammonia,  Palpitation 

Caused  by,  263,  cf.  413. 
Linseed  Poultices,  Uses  of,  255. 
Lipoids,  Narcotic  Action  of,  275. 
Liquid  (see  also  Fluids),  Diminution 

of,    in  Oertel's    Treatment, 

250. 

-  Diet,  Effect  on  Excretion  of  Urine, 

347. 

-  Paraffin,  for  Constipation,  431. 

-  Part  of  Blood,   Leakage  of,  into 

Tissues,  9. 

Liquor  Carbonis,  or  Picis  Carbonis,  in 
Relief  of  Pruritus  ani,  429. 

-  Strychninte  (see  also  Strychnine), 

with  Salicylate  of  Soda  in 
Cardiac  Failure  of  Acute 
Rheumatism,  375. 

Liquorice,  to  Mask  Taste  of 
Iodides,  341. 

Lister,  Lord,  on  Motor  and  Peri- 
staltic Action  of  Arteries, 
8-9. 

Literature,  see  Bibliographies. 

Liver,  Action  of,  394  et  sqq. ;  Im- 
perfect, Signs  and  Results, 
382. 

-  Appearance  of,  in  Life,  and  after 

Death,  20. 

-  Circulation  through,  see   Entero- 

hepatic  Circulation. 


5oo 


INDEX 


Liver  (cont.) 

-  Congested,  Size  Reduced  by  Digi- 

talis, 811. 

-  Distensibility  of,  19,  20. 

-  Effect  on,  of  Disordered  Circula- 

tion, 229,  of  Venous  Engorge- 
ment, 223-4. 

-  Leeches    over,    Relief    from,    in 

Hepatitis,  258. 

-  Massage  of,  Objects  of,  238,  396. 

-  Pressure  on,  Chief  Agent  in  Bile 

Evacuation,  395-6. 

-  Reflex  Stimulation  from,  of  Vagus, 

Brad  yeardia  from,  167. 

-  Secretions   of,    Internal   and   Ex- 

ternal, 89. 

-  Stimulation    of,    in  Acute  Rheu- 

matism, by  Calomel,  875. 
Local   Anaesthetics;    Cocaine    with 
Adrenalin  as,   Mode  of  Ac- 
tion of,  384;    Ether  Spray, 
261. 

-Application  for  Acute  Rheuma- 
tism, 375-6. 

-  Inflammations  with  General  Febrile 

Disturbances,  Use  of  Aconite 
in,  829. 

-  Modifications  of  the  Circulation,  by 
—  Aconite,  258 

-  -  Bleeding,  257-60. 

-  -  Heat  and  Cold,  253-7. 

-  -  Hot  Air  Bath,  257. 
Locomotive  Arteries,  Pulse  Tracings, 

(figs.)  134, 185. 
Locke's     Modification    of    Ringer's 

Fluid,  Use  of,  278. 
Lotions  for  Anal  Use,  in  Relief  of 

Pruritus  ani,  429. 
Ludwig,  Carl,  Artificial  Circulation 

Invented  by,  267. 
Ludwig's  Ganglion,  in  Frog's  Heart, 

27,  56. 

-  Kymograph,  15,  95,  (fig.)  16. 

-  Theory  of  Secretion  of  Urine,  346. 
Lumen  of  Arteries,  Effect  of  Contrac- 
tion of,  204. 

Lungs,  Alveoli  in,  Stiffness  of,  as 
Cause  of  Cardiac  Breathless- 
ness,  182. 

-  in  Cardiac  Dyspnoea,  196, 197. 

-  Circulation  through,  77, 196. 

-  Effect  on,  of  Abdominal  Distention, 

239. 

-  -  of  Disordered  Circulation,  229-30. 

-  Inhalation  by,  of  Tobacco  Smoke, 

325-6. 

-  Motor  Fibres  of  Vagus  possibly 

going  to,  67. 


Lungs  (<ont.) 

-  Reflex  Stimulation  from,  of  Vagus, 

Effects  on  Heart,  73. 

-  Rise  of  Pressure  in,  Heart  Stop- 

page   from,    Valsalva's    Ex-  t 
periment,  172. 

Lying  down,  Difficulty  of  Breathing 
in,  Causes  of,  284. 

-  and  Standing,  Difference  of  Pulse- 

rate  in,  162. 

Lymph  and  Blood,  12-14. 
-Circulation,  How  Aided,  10,  (fig.)  . 

ib. ',    How    Maintained,    14, 

154-5. 

Lymph  Hearts,  in  Frogs,  14. 
Lymphatic  Vessels,  within  Arterial 

Sheath,  10,  166-7,  (ftg».)  10, 

156 ;  Valves  in,  10. 

-  -  Coronary,      Condition     during 

Diastole,  154. 

MACKENZIE'S  Method  of  taking 
Sphygmograms  of  Venous 
Pulsation,  136,  (fig.)  187. 

Macrophags,  Functions  of,  Normal, 
and  in  Senility,  208-4,  (figs.) 
208. 

Magnesia,  Forms  of,  suited  for  Use 
in  Urticaria,  451. 

-  Cream  as  Antacid,  357. 
Magnesium, Hydroxide  of,  in  Stomach 

Acidity,  357. 

-  Peroxide  of,  as  Gastric  Antiseptic, 

356. 

-  Sulphate  of,  for  Chronic  Urticaria, 

451. 

Malnutrition,  from  Grief,  160. 
Mammalian  Heart,  see  under  Heart. 
Mammals,  Action  in,  of  Digitalis,  298. 

-  or  Frogs,  Ludwig's  Apparatus  for 

keeping  up  Artificial  Circu- 
lation in,  271-2. 

-  Normal  Pulse-rate  in,  163. 

-  Vagus     Nerve     in,    Accelerating 

Fibres  in,  71. 

"  Man,  as  old  as  his  Arteries,"  truth 
of  saying,  156,  201. 

-  Blood  -  pressure  in,  Averages,  96, 

110,    Measurement    of,    100 
et  sqtj. 

-  -  High,  Characteristics  found  with, 

452. 

-  Brain  of,  in  Sleep  and  in  Waking, 

363. 

-  Depressor  Nerve  in,  Function  of, 

65. 

-  Heart    of,    see  Heart,   &    Heart 

Mammalian. 


INDEX 


501 


Mania,  Bradycardia  in,  166. 
Manometer,    see    also    Kymographs, 
Sphygmomanometers,  £c. 

-  Experiments  with,  by  Blake,  on 

Digitalis-action,  295. 

-  Used     in    Artificial    Circulation 

through  Mammalian  Heart, 
272. 

-  -  in    Investigation   of    Action    of 

Drugs  on  Frog's  Heart,  268-9. 

-  Various  Forms  of 

-  -  Burdon-Sanderson'sBecording,15. 

-  -  Fick's,  Spring,  96. 

-  -  Hales's,  the  earliest,  15. 

-  -  Hiirthle's,  96. 

—  Ludwig's  Begistering,  15. 

-  -  Mercurial,  15,  95-6, 105,  (figs.)  16, 

95, 106. 

-  -  Poiseuille's,  15. 

-  -  Boy's,  96. 

Marey,  Cardiograph  devised  by, 123-6. 

-  Sphygmograph    of,    16,    127,    ac- 

curacy of,  135. 
Marsh  Gas,  one  of  the  Chief  Intestinal 

Gases,  Derivation  of,  355, 857. 
Martin's  Sphygmomanometer,  105. 
Mask,  for  giving  Oxygen,  241. 
Massage,  see  also  Self-Massage. 

-  in  Aneurism,  454-5. 

-  in    Combination  with  Best,  236, 

Effects  of  the    Two,    237-9, 
(fig.)  240. 

-  Gentle,  for  Insomnia,  364,  429,  432. 

-  and  Graduated  Movements,  Effect 

of,  on  Pulse,  Io8,(fig.)  157,240. 

-  in  Graves's  Disease,  416. 

-  of  Liver,  for  Biliousness,  396. 

-  for  Menstrual  Headache,  449. 

-  Use  and  Abuse  of,  287,  397. 
Mastication,  Importance  of,  379,  382, 

383-4,  389. 
Mastoid  Process,  Application  over,  of 

Leeches,  benefits  from,  257-8. 
Meals,  Anginal  Pain  after,  190. 

-  Latest  Time  for,  in  Insomnia,  431. 

-  Small  and  Frequent,  Advantages 

of,  384-5. 

-  Solids  and  Fluids,  best  not  taken 

together  at,  384. 

Meat    Boiled,    Saltless,    in    Mitral 
Disease,  253. 

-  in    Diet    of  Convalescents    from 

Acute  Heart  Disease,  379. 

-  Extracts  of,    Contra-indicated   in 

Angina  Diet, -448. 

-  -  Stimulant  Value  of,  288. 

-  Putrid,  Amines  from,  Acting   as 

does  Suprarenal  Extract,  91. 


Meat-teas,  for  Cardiac  Patients,  886 ; 

in     Rheumatic   Fever   Diet, 

372-3. 
Mechanical  Stimulation  of  Pylorus, 

389. 
Median    Cephalic,    or   Basilic  Vein, 

utilised  in  Blood-letting,  259. 
Medicines,  see  Drugs,  Extracts,  and 

under  Names. 
Medinal,  as  Hypnotic,  485. 
Medulla    Oblongata,   Action  on,    of 

Digitalis,  298,  303,  307. 

-  -  Disease  or  Injury  of,  Bradycardia 

in,  167. 

-  -  Electrical  Stimulation  of,  Effect 

on  Frog's  Heart,  39. 

-  -  Nerve-centres  in,    securing   Co- 

ordination of  Heart's  Action 
and  Blood-pressure,  17-18. 

Inhibitory,  Action  of,  on  Pulse- 
rate,  161-2. 

Excessive  Action  of,  in  Re- 
lation to  Bradycardia,  166, 
Injury  to,  in  Regard  to  the 
same,  167. 

•  -  Reflex  Irritability  of,  Increased 

by  Strychnine,  316. 

Respiratory  Rhythm  origin- 
ated by,  27. 

of  Vagus,  Action  on,  of  Digi- 
talis, 298,  303,  307. 

Vaso-motor,  Chief,  85. 

Action  on,  of 

Camphor,  316. 

Digitalis,  298. 

Nicotine,  323-4. 

-  -  N<eud  Vital  of,  61-2 ;  Gierke's  In- 

vestigations of,  62,  (fig.)  ib. 
Medullary    portion     of    Suprarenal 

Gland,  Effect  on   Heart,  of 

Disease  of,  289. 
Medusa;,  Comparison  between,  and 

the  Heart,  88  et  sqq. 

-  Contractile  Tissue  in,  34,  (fig.)  34. 

-  -  Action  on,  of 

-  -  Compression,  &c.,  86. 
Poisons,  86. 

Stimuli,  Successive,'  and  Con- 
stant, 33,  85. 

-  Inhibition  in,  Phenomena  of,  86, 

39. 

-  Rhythmic     Movements    of,    De- 

pendent on  Ganglia,  34,  35. 

-  Structure  of,  84. 
Melancholia,  Bradycardia  in,  167. 
Meningitis,  Leeches  in,  Relief  from, 

257. 

-  Vagus  Stimulation  in,  420. 


502 


INDEX 


Menopause,  Blushing,  and  Heat 
Flashes  at,  &c.,  and  Treat- 
ment, 177,  450. 

Menstrual  Period,  Headache  of,  Path- 
ology and  Treatment,  449. 

Mental  Aftections,  Bradycardia  in, 
166-7. 

-  Deterioration,    from    Rupture    of 

Cerebral  Vessel,  202. 

-  Disturbance  from  Disordered  Cir- 

culation to  Frontal  Lobe  of 
Brain,  205-6. 

-  Excitement,  and  Irritation,  Seda- 

tives for,  in  Palpitation,  413. 

Mentha  Piperita,  and  Viridis,  Oil, 
Spirit,  and  Water  of,  as  Car- 
minatives, 360,  Adjuncts  to, 
361,  439. 

Mercurial  Inunction,  in  Cerebral 
Thrombosis  of  Syphilis,  457. 

-  Manometers,  105,  (figs.)  16, 106. 

-  Purgatives  (see  also  Calomel),    in 

Senile  Conditions  of  Vessels, 
453. 

-  Sphygmomanometers,  102-5,  114. 
Mercurials,  Action  of,  on  Bile  and  its 

Toxins,  353-5. 

-  and  Salines,  in  Angina  Pectoris, 

443;  in  Relief  of  Headache, 
447,  448,  in  Bradycardia,  420. 

-  in    Senile    Conditions    of  Blood- 

vessels, 453. 

-  in  Syphilitic  Heart-block,  437. 
Mercury,  Ammoniated,  Ointment  of, 

for  Eruption-Pustules  due  to 
Iodides,  342. 

-  as  Diuretic,  Theories  on  its  Action, 

350-1 ;  Forms  of,  as  Intestinal 
Disinfectant,  359. 

-  with     Iodide    of    Potassium,    in 

Stokes- Adams  Disease,  421. 

-  Perchloride,  as  Intestinal   Disin- 

fectant, 359. 

Metabolism,  Exercise  as  Aid  to,  396-7. 
Methods   of  Treatment    in  Cardiac 

Disease,  232  et  sqq. 
-  -  Bibliography,  264-5. 
Methyl     Salicylate,     in     Rayuaud's 

Disease,  450. 

-  -  and     Menthol     Ointment,    for 

Pruritus  ani,  430. 

Methylxanthine,  288. 

Microbes,  Pathogenic, Associatedwith 
Cardiac  Inflammation,  151-2. 

Micro-organisms,  Causing  Septic 
Endocarditis  and  Pericar- 
ditis, Route  of  Entry,  and 
Examination  for,  378. 


Microphags,  Functions  of,  203. 

Micturition,  Rising  for,  Risk  of  Fatal 
Syncope  from,  in  Excessive 
Use  of  Digitalis,  313. 

Migraine  (see  also  Headache); 
Aphasia  with,  Author's  Ob- 
servation, 186. 

-  Compression  of  Vagi  in,  Success  of, 

419. 

-  and  Epilepsy,  du  Bois-Reymond's 

Views  on,  186. 

-  Nervous     Symptoms    Associated 

with,  185. 

-  Pathology  of,  Experiences  of  du 

Bois-Reymond  and  Author, 

153-4,  446,  (flg.)lS4. 
Migrainine,  for  Headache,  448. 
Milk,  in  Acute  Cardiac  Diseases,  374. 

-  Amounts  in,  of  Calcium  and    of 

Chlorides,  in  Relation  to 
Milk  Diet  in  Cardiac  Disease, 
253. 

-  Casein   of,   non-Nutrient   to    the 

Heart,  286. 

-  Contra-indicated       in       Cerebral 

Thrombosis,  456. 

-  in  Diet  in  Aneurism,  aim  of,  455. 

-  Diet  in  Insomnia,  Drawbacks   to, 

430-1,  Modifications  of,  430-1. 
—  in  Rheumatic  Fever,  Adjuncts, 
Permissible,  to,  372-8. 

-  Souring  of,  Best  Method,  859. 

-  Warm,  Whisky  or  Brandy  in,  as 

Hypnotic,  433. 
Mistletoe,  Preparation  of,  for  Angina 

Pectoris,  444. 
Mitral  Valves,  Action  of,  Benefited 

by  Digitalis,  309. 

-  -  Competence  of,  in   Relation   to  j 

Shortness  of  Breath,  408. . 

-  -  Disease  of,  Albumen  in  Urine  in, 

not  a  Contra-indication  for 

Opium,  365. 

Diet  Advisedin.by  Schott,250-l. 

Double  Effect  of,  351,  ( fig.)  352. 

Fluid-limitations  in,  by  Schott, 

251. 
Treatment    of,    by    Rest   and 

Entire  Milk  Diet,  258. 

-  -  Incompetence  of,  in  Aortic  Dis- 

ease, Treatment,  407. 

-  -  Cardiac  Murmur  due  to,  213-4. 

from  Disease,  Effect  on  Cardiac 

Rhythm,  220. 
Functional  (Secondary),  Effects  | 

of,  219. 

-  -  Murmurs  of,  Temporary,   How 

Caused,  75,  216. 


INDEX 


503 


Mitral  Valves  (cont.) 

-  -  Obstruction    of,   Breathlessness 

due  to,  182. 
Cardiac  Murmur  Indicative  of, 

214-5. 
Causes  and  Effects,  221-2. 

-  -  Feeble  Heart  from,  158. 

—  Regurgitation  in,  78. 

Breathlessness  due  to,  182. 

and  Cardiac  Bounds,  211,  214, 

217. 

Causes,  215. 

Conditions  in,  and  Treatment, 

407-9,  438,  (fig.)  75. 

Feeble  Heart  due  to,  158. 

—  Frequency     of,    Unsuspected, 

Powers    of    Patients    with, 

408-9. 
Functions,  215,  (fig.)  75. 

-  -  Organic,    Causes    and    Results, 

220-1,  (fig.)  220. 
Treatment,  403,  407,  438. 

—  Stenosis  of,  Cause,  215. 
Conditions  in,  407-8. 

-  -  and  Independent  Pulsation  of 

Certain  Veins,  22. 
-  Treatment  of,   438 ;    Author's 

Proposed      Operation      for, 

407-8. 
Monoplegia,  from  Haemorrhage,  145 ; 

from  Obstruction  of  Sylvian 

Artery,  205. 
Montgomery,  Lord,  Exposed  Heart 

of,  186. 

Morbid  Blushing,  Treatment,  449-50. 
Morning  Headache,  Preventive  Treat- 
ment, 449. 
Morphine,  Action  of,  as  Attected  by 

Inurement,  279-80. 

—  as  Antipyretic,  284. 

-  -  as  Hypnotic,  436-7. 

-  -  as  Narcotic,  278,  284. 

-  Injections  of 

—  in  Angina  Pectoris,  442. 

-  -  Hypodermic.for  Cardiac  Asthma, 

448;  for  Endocarditis  Pain, 

376. 

Mosso's  Plethysmograph,  180. 
Motor  Action  of  Arteries,  7,  8. 

-  Disturbances,  Functional,  of  Cere- 

bral Motor  Centres,  Causa- 
tion, 186. 

-  Fibres  of  Vagus,  going  to  Abdo- 

minal Organs,  &c.,  67. 

-  Nerves,    in    Voluntary    Muscles, 

Effect  on,  of  Small  Doses  of 
Curare,  275. 

-  Power  of  Lymph  Circulation,  14. 


Mouth  (see  also  Oral),  Acid  Secretion 
in,  Headache  from,  447. 

-  Dryness  of,  How  Induced  by  Atro- 

pine,  274. 

-  Irritant   Action   on,    of  Tobacco 

Smoking,  Results,  326,  327. 
Mouth-washes  for  Relief  of 

-  Aching  Teeth,  426. 

-  Headache,  447. 

-  Pyorrhoea  alveolaris,  383. 
Movements   (see   also  Exercises)   of 

Heart,  25  et  sqq.,  of  the  same 
when  Excised,  How  Re- 
corded, 26. 

-  Slow,  for  Angina  Patients,  444. 
Mucous    Membrane,    Action  on,  of 

Acid  Chyme,  393. 

-  -  Acid  and  Pepsin  in,  391. 

-  -  Catarrh   of,  and  thickening  of, 

Action  of,  on  Pylorus,  3&9-90, 

(fig.)sgo. 

-  -  Gastric,  Sedative  Treatment  of, 

420. 

-  -  Xasal  of  Animals,  Irritation  of, 

Effects  of,  on  Vagus  and 
Heart,  73. 

—  Pulmonary,  Secretion  of,  in  Car- 
diac Dyspnoea,  197. 

Mucus,  Action  on,  of  Alkalies,  387. 

Murmurs,  see  Cardiac,  and  Sounds  of 
Heart. 

Muscarine,  Action  on,  of  Pilocarpin, 
Seasonal  Difference  in,  282. 

-  Antagonistic  Alkaloids  in,  278. 

-  Heart-stoppage  by,  in  Frogs,  280, 

Action  of  Camphor  after, 
316. 

Muscle-cells,  Contraction  of,  Fibrilla- 
tion Caused  by,  62-S,  (fig.)  51. 

Muscle(s),  see  under  Names. 

-  Accessory,  of  Circulation,  12,  229, 

397. 

-  Blood-vessels  of,  Sudden  Dilatation 

of,in  Relation  to  Syncope,  181 . 

-  in  Differentiated    Protoplasm,  as 

Affected  by  Stimuli,  28-9. 

-  Elongation  of,  85,  86,  87. 

-  Exercise  of,  Benefit  of,  397. 

-  Feeble   Circulation    in,    in    Rest, 

Massage  for,  236-S. 

-  Injured  by   Direct   Contact  with 

Blood,  13. 

-  Involuntary,    Tone    in,    Defined, 

288-9. 

-  Involved  in  Bending  a  Finger,  240. 

-  Stimulation  of.Etfect  of.onArteries 

Connected,  397. 

-  as  Vascular  Area,  19. 


504 


INDEX 


Muscular  Action,  Effectof,  on  Lymph 
Circulation,  14. 

-  Areas,    Influence    of,    on    Blood- 

pressure,  18. 

-  Cells  of  Arterioles,  Contraction  in, 

Two  Possible  Forms  of,  86, 
(fig.)  ib. 

-  -Cardiac,  Transverse  Contraction 

of,     as    Affecting    Poisons, 
Author's  Hypothesis,  270-1. 

-  Conduction  of  Stimuli  in  Heart, 

46-7,  (fig.-)  45. 

-  Contraction,  as  Affecting 
Blood-pressure,  110. 

•  -  Venous  Circulation,  10. 

-  -  of    Auriculo-ventricular     King, 

Aid  of,  to  Heart  Valves,  75, 
(fig.)  ib. 

-  -  of  Heart,  Action  on,  of  Caffeine, 

in  Small  Doses,  288. 

-  Two   (Possible)   Modes    of,    86, 

(fig.)  Ib. 

-  Fibres  of 

-  -  Arterioles,  Action  on,  of  Digitalis, 

298. 

-  -  Bronchioles,  in  Cardiac  Dyspnoea, 

197. 

-  -  Heart,  50-2 ;  Action  on,  of 

-  -  Bacteria  and  Toxins,  152, 158. 

Block  of  Coronary  Arteries,  158. 

Caffeine  and  Purins,  817-9. 

Digitalis,  298,  807. 

Diphtheritic  Toxins,  152, 160. 

-  Layer,  Continuous,  of  Arterioles, 

84. 

Nerve  Fibrils  over,  58,  85,  (fig.) 

85. 

-  Organs,      Hollow,     see      Hollow 

Muscular   Organs,    see    also 
Heart. 

-  Kings  round  Auriculo-yentricular 

Orifices,    Benefit    to,    from 
Digitalis,  809. 

-Structures,  Connected  with  Circula- 
tion, Action  on,  of  Digitalis, 
Stages  of,  801-8. 

-  -  of  Mammalian  Heart,  50-2. 

-  Wall  of  Intestine,  Weakened  Expul- 

sive Power  of,  Action  on,  of 
Pituitary  Extract,  802. 

-  Waste,  Narcotic  Products  of,  868. 

Musculi  papillares,  Fatty  Degenera- 
tion Patches  Affecting,  De- 
duction from,  161. 

-  -  Fibres  ending  in,  57. 

-  -  Regurgitation  due  to   Irregular 

Action  of,  217,  218. 
Mussels,  as  Cause  of  Urticaria,  450. 


Mustard  Flour,  Poultices  of,  Applica- 
tion of,  255 ;  Kedness  from, 
Immediate  and  Later,  Prob- 
able Causes,  89. 

-  Leaves,  in  Cerebral  Haemorrhage, 

455. 

-  and  Water  Emetic  In  Relief  of 

-  -  Paroxysmal  Tachycardia,  418. 

-  -  Stomach  Irritation,  488. 
Myocarditis,  Causes,   161-2 ;    Quick 

Pulse  Indicative  of,  168. 

-  Acute,  Onset  of,  during  various 

Diseases,  Outlook  for,  867. 

-  Chronic,     Bradycardia     in     Con- 

valescence from,  Treatment, 
420-1. 

-  -  Diet  in,  Advised  by  Schott,  251. 

-  -  Paroxysmal  Bradycardia  in,  168. 

-  Interstitial,  associated  with  Tachy- 

cardia, 165. 
Myocardium,  Effect  on,  of  Certain 

Bacteria,  162. 
Myogenic  Theory  of  Cardiac  Rhythm, 

27,  80. 
Phenomena  Explained  by,  40 ; 

others      Un-explained     by, 

82-3,  84. 

Practical  Importance  of,  47. 

Myristica,    Oil    and    Spirit    of,    as 

Carminatives,  860. 
Myxcedema,  Effects  in,  of  Protracted 

Use  of  Thyroid  Extract  by 

Mouth,  165. 

NAPOLEON  I.,  Slow  Pulse-rate  of,  166. 

Naphthalin  as  Intestinal  Disinfect- 
ant, S(>0. 

Naphthol,as  Gastric  and  Intestinal 
Antiseptic  and  Disinfectant, 
856,  859. 

Narcotic  Action  of 

-- Aliphatics,275. 

-  -  Leucomaines,  theory  of,  863. 

-  -  Lipoids,  276. 

-  -  Morphine,  284. 

-  Poisons    in    Blood,    as    affecting 

Cerebral  Activity,  425. 

Narcotics,  in  Cardiac  Complaints, 
863-5. 

Narghileh,  see  Huka. 

Nasal  Affections,  Headache  from, 
447,  Treatment,  447. 

Nauheim  Treatment,  Cardiac  Affec- 
tions suited  to,  248,  403,  404, 
409;  Methods  and  Results, 
243  et  sqq.,  (figs.)  246,  247; 
After-cure,  249-50;  Author's 
personal  observations  on,  249 


INDEX 


505 


Nausea,  of  Digitalis  Poisoning,  808-4. 
Necrosis,    Local,    of  Cardiac   Wall, 

Causes  and  Results,  153. 
Needle,  Ordinary,  for   Tapping   for 

(Edema,  260. 
Nephritis,   Blood-pressure    Rise   in, 

91. 

-  Acute,  Wet-cupping  in,  benefit  of, 

258. 

-  Chronic     Interstitial,     Rise     in, 

of   Blood-pressure,    possible 

Causes  of,  91-2. 
A'eriwm  oleander,  811. 
Nerve-cells 

-  Bipolar,  of  Heart,  53. 

-  Cerebral,  Destroyed  by  Macrophags 

in  Old  Age,  203-4,  (fig.)  203. 

-  Condition  of,  Dependent  on  Cir- 

culation, 368. 

Nerve-centres,  Action  on,  of  Nitrite 
of  Amyl,  276. 

-  Stimulated  by  Strychnine,  316. 

Nerve-fibres,  in  Differentiated  Proto- 
plasm, as  affected  by  Stimuli, 
28 ;  of  Heart,  52-3,  85. 

Nerve-fibrils,  Net-wise  over  Muscular 
Layer  of  Arteriole,  53,  85, 
(fig.)  85. 

Nerve-ganglia  of  the  Heart,  Functions 
of,  40-2,  85,  824. 

Nerves,  see  under  Names. 

-  Drugs  acting  on,  47. 

-  -  Selective  Action  of,  275. 

-  Extrinsic,  of  the  Heart,  63  et  sqq. 

-  Intrinsic,  of  Heart,  52-8. 

-  -  Afferent,  in  Epicardium,  64. 

-  -  Sensory,  53-4. 

-  Irritation   of,  from   Severe   Pain, 

Stoppage  of  Heart  from,  178. 

-  Massage  of,  in  Health,  by  Arterial 

Contraction  and  Expansion 
(see  Self-massage  of  Arteries), 
236-7. 

-  of  Arterioles  and  Veins,  Research 

on,  85  (c/.  58). 

-  of  Blood-vessels,  Opposing  Action 

of,  85. 

-  Plexus  of,  accompanying  Coronary 

Arteries,  63,  (fig.)  54. 

-  -  Anterior  Cardiac,  63,  (fig.)  54. 

-  of  Special  Sense,  affecting  Pulse- 

rate,  72. 
jY«rt>i  erigentes,  Dilatation  of  Vessels 

by,  how  Induced,  87. 
Nervous     Bundle,    forming     Nceud 

Vital  of  Medulla,  62. 

-  Conduction  of  Stimuli  in  Heart, 

46-7,  (figs.)  45. 


Nervous  (cont.) 

-  Depression,    as    Cause   of   Feeble 

Pulse,  Causes   and   Result, 
158-60. 

-  Ganglia,  Injured  by  Direct  Contact 

with  Blood,  13. 

-  Irritability  of  Bradycardia,  Treat- 

ment, 420. 

—  of    Graves's    Disease,    Bromide 

Treatment  of,  416. 

-  People,      Pulse-rate     in,      under 

Excitement,  163,  (  fig.)  164. 

-  Structures  and  System  concerned 

in  Circulation,  Action  on,  of 
Digitalis.Stages  of,  301, 302-3. 

-  Symptoms,   associated    with    Mi- 

graine, 185. 

-  System,  Action  on,  of  Digitalis,  298, 

of  other  Drugs,  846. 

-  -  Centres  affecting  Co-ordination  of 

Heart's    Action  and   Blood- 
pressure,  17-8,  161. 

Concerned    in    Angio-neurotic 

(Edema,  199. 

-  -  Central,  Chief  Controlling  Factor 

of  Pulse-rate,  161. 

-  -  Peripheral,  of  Heart,  Action  on, 

of  Caffeine,  and  other  Purin 
Bodies,  317-8. 

—  Tremor,from  Excessive  Smoking, 

327. 
Nervousness,  Bigeminal  Pulse  from, 

170-1,  (fig.)  171. 
Nettle-rash,  see  Urticaria. 
Neuralgia,  Intercostal,  Cardiac  Pain 

from,  440-1. 
Neuralgic  Element  in  Pain  of  Angina 

Pectoris     Attacks,      Treat- 
ment, 442. 
Neurasthenia,  associated  with  Low 

Tension,  451. 
Neuritis,     Alcoholic,    Paralysis     of 

Vagi  from,  Pulse-rate  in,  168. 

-  of  Vagus,  probable  Cause  of  Brady- 

cardia after  Diphtheria,167-8. 
Neurogenic  Theory  of  Cardiac 

Rhythm,   27;  Difference  of, 

from  Myogenic  Theory,  30 ; 

Practical  Importance  of,  47. 
Neuro-muscular  Cardiac  Nerves,  52. 

-  Cells,  in  Fresh-water  Hydra,  28-9, 

(figs.)  29. 

-  Fibres  of  Purkinje,  57,  (fig.)  68. 
Neurons,  Dendronsof.Nature  of,200n. 
Newt,    Kidney    of,    Circulation    in 

(fig.),  348. 

Nicolai's  Method  of  Lettering  Electro- 
cardiograms, 142-8,  144. 

2  L 


506 


INDEX 


Nicotine,  absorbed  by  Chewing,  or 
Snuffing  Tobacco,  324-5. 

-  Action  of,  on  Heart  and  Vessels, 

315,  323. 

-  -  Opposite    in    Large   and   Small 

Doses,  277,  327. 

-  -  Selective,  276. 

-  Paralysis  by,  of  Inhibitory  Vagus 

Fibres,  71-2. 

Nightstools,  see  Commodes. 
Nitrateof  Potash, as  Vaso-dilator,889. 

-  -  with  Nitrite  of  Sodium,  in  Senile 

Conditions  of  Vessels,  453. 
Nitrates,  as  Vase-dilators,  336,  339, 

453. 
Nitrites,  see  Amyl,  Ethyl,  £  Sodium 

Nitrite,  s««  also  Vaso-dilators. 

-  Action  of,  less  on  Pulmonary  than 

on  General  Circulation,  445. 

-  -  as  Vaso-dilators,  838,  338. 

-  Amplitude  of  Pulse  Increased  by, 

158. 

-  in  Angina  Pectoris,  441. 

-  Failure  of,  in  Renal  Disease,  92. 

-  in  Belief  of  Headache,  448. 
Nitrobutyl,  in  Angina  Pectoris,  441. 
Nitroerythrite,  as  Vaso-dilator,  889. 
Nitroerythrol,  as  Aperient  in  Angina 

Pectoris,  443. 

-  as  Vaso-dilator,  339,  453-4. 
Nitrogenous    Diet,   Contra-indicated 

in  Paroxysmal  Tachycardia 
in  Gouty  Persons,  419. 

-  -  Effect  on  Excretion  of  Urine,  347. 

-  -  in    Senile   Conditions  of  Blood- 

vessels, Drawbacks  to,  452. 
Nitro-glycerin,  in  Angina  Abdominis, 
atidAnginaPectoris, 196,441-2. 

-  as  Dilator  of  Coronary  Vessels,  344. 

-  and  Strophanthus  for  Chilblains  of 

the  Elderly,  450. 

-  Uses  of,   886-8,   Author's  Investi- 

gations, 368. 

-  as  Vaso-dilator,    389,   in    Palpita- 

tion, 413. 
Nitro-hydrochloric  Acid,  after  Meals, 

to  aid  Digestion,  387-8. 
Nitromannitol,  as  Vaso-dilator,  339. 
Nitrous  group,  as  Vaso-dilators,  339. 
Nodal  Bhythm,  58,  cf.  80. 
Nodes,    A-V,    57,    Transmission    of 

Stimuli  through,  286. 

-  of  Heart,  Accelerator  Nerves,  prob- 

ably acting  through,  72. 

-  Connection  of,  57. 

-  -  Nature  of;  Origin  in,  of  Contrac- 

tion Stimuli  in  Heart,  56. 

-  -  Structure  of,  57. 


Nodes  (con  (.) 

-  8-A,  other  names  for,  57. 
Nodular  Arterio-sclerosis,  Patch  of 

formation  of,  199. 
Nceud  Vital  of  Heart,  61-2,  (  fig.)  62. 

-  -  of     Medulla     Oblongata,    61-2,  ' 


Nomotopic  Ventricular  Contraction, 

58. 

Normal  Pulse,  ste  under  Pulse. 
Nose  (see  also  Nasal),  Mucous  Mem- 

brane of,    Irritation   of,   in 

Animal,    Effects    on   Vagus 

and  Heart,  78. 

Novocaine,  as  Local  Anaesthetic,  261. 
Nutrient     Enemata,     in     Cerebral 

Haemorrhage,  456. 

-  Fluids,  used  in  Artificial  Circula- 

tion    through     Mammalian 

Heart,  278. 

Nutrients,  Cardiac,  284  et  siju. 
Nutrition  of  Blood-vessels,  as  affected 

by  Cardiac  Feebleness,  157, 

(fig.)  ib. 

-  Failing,  from  Disease,  Fatty  Degen- 

eration of  the  Heart  in,  151. 

-  General,  benelited  by  Digitalis,  811. 
-of  Heart,  150-1. 

-  -  benefited  by  Digitalis,  308-9. 
--Effect   on,    of  its   own    Feeble- 

ness, 154. 

--Saline     Solution,    Simple     and 
Compound,  in,  285-6. 

-  in  Heart  Disease,  Importance  of, 

366-7. 
Nutritive  Action  of  Cardiac  Tonics, 

155-6. 
Nux  Vomica,  see  also  Strychnine. 

-  Action  in  Belief  of  Insomnia,  483. 

-  -  in  Palpitation  of  Debility,  414, 

Prescription  for,  489,  When 
Taken,  414. 

-  Tincture    of,    with   Salicylate   of 

Soda,  in  Cardiac  Failure  of 
Acute  Rheumatism,  375. 

-  as  Tonic  for  Bradycardia  of  Fever( 

Convalescence,  421. 

OATMEAL  Poultices,  Uses,  255. 
Obstruction,    see   Aortic,    Coronary, 

Mitral,  Sylvian,  Ureteral,  <tc. 
Occipital  Artery  in  Migraine,  (fig.) 

184. 
(Edema  (see  alto  Ascites,  A  Serous 

Effusion),    Causes    of,    223, 

224,  310. 

-  Action  on,  of  Digitalis,  308,  310-11. 

-  Angio-neurotic,  810. 


INDEX 


507 


(Edema  (cont.) 

-  of  Feet  and  Ankles,  223. 

-  of  Limbs,  Massage  and  Rest  for, 

239. 

-  -  Tapping  for,  260. 

-  Ranviers  Experiment  on,  Deduc- 

tions, 310. 

-  of  Tissues,  Calomel,  and  Purga- 

tives to  Cause  Absorption  of, 
850-1,  353. 

-  Universal,  from  Anti-Streptococci 

Serum,  199. 

CErtel's  Treatment,  Principles  and 
Rules  of,  250-1;  in  Cardiac 
Asthma,  445. 

Oil  of  Eucalyptus,  in  Septic  Endo- 
carditis and  Pericarditis, 
378-9. 

-  of  Juniper,  as  Diuretic,  350. 

Oils,  Essential,  &c.,  as  Carmina- 
tives, 360,  361. 

-  Ethereal,  as  Diuretics,  350. 
Ointments,  for  Anal  Itching,  430. 

-  for     Eruption-pustules,     due     to 

Iodides,  342. 

-of  Salicylate  of  Methyl,  in  Ray- 
naud's  Disease,  450. 

-  Sedative,  for  Cardiac  Pain,  441. 

Old  People  (see,  also  Elderly,  <£  Senile),   j 
Arterial    Changes    in,    126, 
132-3, 194,  199,  (figs.)  134. 

-  -  Brown  Atrophy  in,  153. 

-  -  Cerebral  Nerve-cells  of,  Destroyed   | 

by  Macrophags,  203-4,  (fig.)   I 
203. 

-  -  Patty    Degeneration    of    Heart   ' 

in,  151. 
Olfactory  Centre,  Disturbance  of,  by 

Arterial  Contraction,  86, 186. 
Oliver's  Arteriometer,  119. 

-  Sphygmometer,  102,  114. 
Opium,  Antagonistic    Alkaloids    in, 

278;  Contradictory  Effects 
of,  according  to  Admini- 
strator,  277. 

-  in   Albuminuria   of    Venous    En- 

gorgement, 225-6. 

-  as  Hypnotic,  Narcotic,  or  Soporific, 

864-5,  486-7. 

-  in  Severe  Bradycardia,  420. 

-  Use  and  Abuse  of,  237. 
Oppression,  Sensation  of,  in  Angina 

Pectoris,  Causes,  188 ;  in 
Grief,  Author's  Experience, 
&c.,  186-7*71. 

Oral  Administration  of  Cardiac 
Stimulants,  in  Endocarditis, 
377. 


Oral  Affections  Causing  Headache, 
Treatment,  446-7. 

-  Hygiene  (sec  also  Mouth  <£•  Teelh), 

Importance  of,  in  Heart 
Disease,  382-3. 

Organic  Cardiac  Murmurs  (see  also 
Sounds),  Causes  and  Indica- 
tions, 214-5. 

-  Diseases  of  the  Heart,  210  et  sqq. 

-  -  Bibliography  of,  230-1. 
Organotherapy  (see  also   Forms   of, 

under  Names),  Effects  of,  on 
Blood-pressure,  89. 
Organs,  in  Activity,  Blood  Supply 
to,  how  Provided,  8. 

-  Supplied  by  the  Vagus  Nerve,  64. 
Oscillation    of   Tension,  see   Blood- 
pressure,  Changes  in. 

Oscillations  in  Arterial  Walls,  Obser- 
vation of,  to  Measure  Dias- 
tolic  Pressure,  114-6  ;  Instru- 
ments for,  114-5. 

Oscillometer  of  Pachon,  115. 

Ossification  of  Arteries,  156,  191,  of 
Aorta, 211,  Claudication  with, 
Burns'  Views,  194-5. 

Oubain  (Acocanthera),  311. 

Ovarian  Extract,  in  Relief  of  Heat 
Flushes  and  Blushing  of 
Menopause,  450. 

Over-Action  of  Heart.  Tendency  to, 
in  Acute  Disease,  how  Best 
Met,  866-7. 

Over-Dose  of  Antipyrin,  &c.,  Effect 
on  Pulse,  437. 

-  of  Chloral,  why  Sometimes  Fatal, 

Treatment,  434. 

-  of  Nitrites,  in   Angina    Pectoris, 

Results,  442. 

Over-Exercise,  Ill-effects  of,  287. 
Over-Massage,  Ill-effects  of,  287. 
Over-Smoking,  as  Cause  of  Low 

Tension,  328,  451. 
Over-Work,  Avoidance  of,  in    Low 

Tension,  451, 
Oxidation  in  Relation  to    Mode   of 

Action  of  Cardiac  Tonics  on 

Embryonic  Heart,  297-8. 

-  and  Reduction  of  Cell-layers,  in 

Relation  to  Cell-funotion,280. 
Oxygen,    Aeration    by,   of   Ringer's 
Fluid,  273. 

-  in  Blood,    Quality  of  Blood   De- 

pendent on, 151. 

-  Inhalation  of,  in  Cardiac  Asthma 

&c.,  240  et  sqq.,  260,  445; 
Medication  for  such  Use, 
241-3,  (figs.)  242-3,  445. 


508 


INDEX 


Oxygen,  Inhalation  of  (eottt.) 

-  -  in  Fainting  in  Aortic  Regurgita- 

tion,  428. 

-  in  Stokes- Adams  Disease,  421. 

-  with    Blood-letting,   in    Cerebral 

Haemorrhage,  455. 

Oxygenation,  to  Relieve  Viscosity  of 
Blood,  147. 

I'ACK-M AKER  of  Heart,  58,  72. 

Pachon's  Oscillometer,  116. 

Pain,  Abdominal,  from  Iodides,  342. 

-  of  Aching  Teeth,  Cold  to  Relieve, 

254,  Mouth-wash  for,  426. 

-  of  Acute  Rheumatism,  Salicylate 

of  Soda  for,  and  Adjuncts  to, 
874-5. 

-  of  Aneurism,  Treatment,  465. 

-  Angina-like      in      the     Healthy, 

Causes,  193,  327. 

-  in  Cardiac  Region  (see  also  Angina). 

-  -  Causes. and  Treatment,  227,  327, 

874-5,  402-3,  407,440-1 ;  Chief 
Seats,  187-8. 

-  of  Colic,  Nature  of,  185. 

-  of  Endocarditis,   Leeches   to    Re- 

lieve, 876. 

-  Good  as  well  as  Bad  Side  of,  451-2. 

-  Local 

-  -  Relief  of,  by 

-  -  Aconite,  258. 

Heat  and  Cold,  253-7. 

-  -  Hot  Air  Bath,  257. 
-  Poultices,  255-7. 

-  of  Pleurisy,  Pericarditis,  or  Colicky 

Nature,    Hot    Poultices    in 
Relief  of,  255-7. 

-  Production  of  (probable),  by  Ex- 

trinsic Afferent  Nerves,  65. 

-  Severe,  from  Irritation  of  Nerves, 

causing    Stoppage    of    the 
Heart,  178. 

-  -  of   Migraine,    Causation,    188-5, 

(fig.)  184. 

Painting  of  Gums,  in  Pyorrhoea 
alveolaris,  solutions  for,  883. 

Pallor,  Facial,  Causes,  7,  8,  20;  in 
Aortic  Regurgitation.219,404. 

Palpitation  of  Heart,  Causes,  Kinds, 
Treatment,  175-7,  219,  262-8, 
327,  407,  411  et  tqq.,  428,  489, 
440,  (figs.)  178,  226. 

Pancreas,  Action  on,  of  Hormones, 
and  Secretin,  398. 

Pancreatic  Ferment,  with  Anti- 
Thyroid  Serum,  417. 

-  Region,Tendernessof,from  Iodides, 

342. 


Paraltin,    Liquid,    to    prevent   Con- 
stipation, 431. 

Paraldehyde,  as  Hypnotic,  Drawback 
to,  How  Got  Over,  438-4. 

Paralysis,  see  also  General  Paralysis,  , 
Homiplegia,  Monoplegia. 

-  of  Heart  and  Vessels,  from  Digi- 

talis, 301-2. 

-  Intestinal,    Post-operative,    value 

in,  of  Pituitrin,  819,  862. 

-  Local,  from  Rupture  of  Cerebral 

Vessel,  202. 

-  Senile,  How  to  Avert,  454. 

-  of  Vagus  and  other  Nerves  from 

-  -  Atropine,  168,  274. 
--Curare,  71,  275. 

-  -  Diphtheria,  160-1,  163. 

-  -  Nicotine,  71,  275,  328-4. 

-  of    Vaso-motor    Nerves,    (Edema 

caused  by,  224. 
Paralytic     Affections,      Cause     of, 

Diagnosis  of,  145. 
Parenchymatous  Degeneration  of  the 

Heart,  162. 
Paroxysmal        Bradycardia,       168, 


.         . 

-  Tachycardia,      Causes,      Nature, 

Treatment,  168-4,  417  et  sqq. 
Pathology  of  the   Circulation,    150 
et  sqq. 

-  -  Bibliography,  178-4. 

Peas,  in  Diet  of  Convalescents  from 
Acute  Heart  Disease,  Masti- 
cation of,  879. 

Pelvic  Organs,  Disturbance  of,  Pal- 
pitation from,  418,  Treat- 
ment, 414. 

Peppermint,  forms  of,  as  Carmina- 
tive, 860,  Adjuncts,  861,  439. 

Pepsin,  Digestive  Value  of,  855,  887, 
419 ;  Rennin  in  Commercial 
forms  of,  888. 

-  in  Mucous  Membrane,  891. 

-  Secretion  of,  892. 
Pepsinogen,  in   Mucous  Membrane, 

891,  Break-up  of,  Result,  892. 
Peptone,  preventing  Coagulation,  90  ; 

non-Nutrient  to  Heart,  286. 
Peptonised     Milk,     for    Dyspepsia, 

430,  431 ;  Drawbacks,  431. 
Peptotoxin,  841. 
Perchloride  of  Iron,  in  Cardiac  Pain, 

with  Quassia,  440,  in  Flushes, 

&c.,  of  Menopause,  450. 

-  of  Mercury,  as   Intestinal   Disin- 

fectant, 859. 

Perfusion  of  Mammalian  Vessels, 
271-2. 


INDEX 


509 


I'ericartiial  Effusion, Different ialDiag- 
nosis  and  Treatment,  377. 

Pericarditis,  Causes,  Results,  Treat- 
ment, 151-2, 255, 258,  263, 377. 

-  Acute,  Causes,  Watch  for,  367. 

-  Septic,   Micro-organisms  Causing, 

Route  of  Entry  Symptoms, 
and  Treatment,  378. 
Pericardium,  Adherent,  Action  of,  on 
Pulse,  487. 

-  AfferentNervesin,Functionsof,64-5. 

-  Effect   of  Painting   of,    with  Co- 

caine, 73. 

-  Irritation   of,  Ventricular  Stand- 

still from,  73. 

-  Purkinje's  Experiments  on,  154-5, 

(figs.)  155. 

-  in  Hepatitis,  Leeches  for,  Relief 

from,  258. 

Peripheral  Action  of  Drugs,  278,  276. 
Peripheral  Blood-vessels,  Fibrillation 

and, 153. 

-  Contraction  of  Arteries,    in    Mi- 

graine, 184. 

-  Ganglia,    Stimulated    by   Strych- 

nine, 817. 

-  Veins,  Contraction  Induced  in,  by 

Adrenin,  87. 

Peristalsis,  Intestinal,  Caused  by 
Injection  of  Large  Dose  of 
Opium  into  Dog's  Vein,  277. 

Peristaltic  Action  of  Arteries,  7,  8. 

Peritoneal  Cavities,  Serous  Effusion 
into,  Effect  on,  of  Massage 
and  Rest,  237,  289. 

-Fluids,  Effect  on,  of  Respiratory 
Movements,  14. 

Peroxide  of  Hydrogen  as  Mouth- 
wash,  383. 

-  of  Magnesia,  as  Gastric  Antiseptic, 

356. 
Perspiration  of  Rheumatic  Patients, 

Clothing,  and   Sponging   to 

Deal  with,  370-1. 
Phagocytes,  two  Classes  of,  Functions 

of,  203-4. 
Pharyngeal    Nerves,    Paralysis    of, 

from  Diphtheria,  160-1. 
Pharyngitis,  Cold  Wet  Compress  in, 

254-5. 

-  Chronic,  from  Excessive  Smoking, 

007 

OAI  . 

Pheasant's  Eye  (Adonis  t>ern.aJis),311. 
Phenacetin  in 

-  Endocarditis,  376-7. 

-  Headache,  448. 

-  Neuralgia,  Effect  on  Pulse  of  Over- 

dose, 437. 


Phenol  Solution,  for  Anal  Relief  of 

Pruritus  ani,  429. 
Phonendoscope,  in  Measurement  of 

Diastolic  Blood-pressure, 11B. 
Phosphorus,   Fatty  Degeneration  of 

the  Heart  Induced  by,  151. 

-  -  Experimental,  in  Dogs,  814. 
Phrynin,  Poison  from  Toads'  Skin, 

Action  of,  similar  to  that  of 

Digitalis,  Story  on,  811-2. 
Phthisis,    Low    Blood-pressure    in, 

181-2. 
Physical  Exertion,  Accentuation  of 

Second  Sound  from,  210-1. 

-  Training,  to  Cope  with  Functional 

Murmurs,  216. 
Physiology  of 

-  Blood-vessels,  and  Blood-pressure, 

84  e<  sqq.;  Bibliography,  96-9. 

-  Circulation,  General,    2    et    sqq.  ; 

Bibliography,  22-4. 

-  Heart,  25  et  sqq. ;   Bibliography, 

47-9. 

-  -  Mammalian,   50 ;   Bibliography, 

78-83. 

Picoline  Bases,  from  Tobacco  Smok- 
ing, 325. 

Pigeons,  Action  on,  of  Morphine,  284. 

Piles,  as  Cause  of  Insomnia,  429. 

Pill-form  of  Mercury  as  Cardiac 
Diuretic,  350. 

-  of  Perchloride  of  Mercury,  Taste 

Concealed  by,  359. 

Pilocarpme,  Action  of,  on  Muscarine, 
Seasonal  Difference  in,  282. 

Pimenta,  Oil  and  Water  of,  as  Car- 
minatives, 360. 

Pipe-smoking,  Difference  between , 
and  other  Forms  of  Smoking, 
325-6. 

Pituitary  Bodies  or  Glands,  Secretion 
of,  and  Maintenance  of 
Heart's  Tone,  289;  Action 
of,  on  Blood-pressure,  90,  on 
Body,  396-7. 

Pituitrin  (Pituitary  Extract),  Action 
of,  319,  844,  on 

-  -  Blood-pressure,  90,  319. 

-  -  Cardiac  Tonic,  819,  320. 

-  -  Intestinal  Paresis,  302. 

-  -  Kidney  Vessels,  319,  344. 

-  -  Shock,  320,  424. 

-  Administration  of,  819, 320,362,424. 

-  Conditions   in    which    Beneficial, 

819-20. 
Plasma,  How  Supplied  to  Heart,  154, 

and  to  Arterial  Walls.  157. 
Plasmon,  in  Mitral  Disease,  253. 


Sio 


INDEX 


Plasters  ovr  Cardiac  Region,  Uses  of, 
262-8,  (fig.)  268. 

-  Use  of,  in  Tapping  for   Ascites, 

261-2,  (fig.),  262. 

Plateau,  Systolic,  in  Senile  Pulse,  126, 
132. 

-  -  Modilications    of,    Evidence    of 

Elasticity  of  Arteries,  188. 
Pleasurable    Ideas    Connected   with 
Food,  Digestive  Value  of,  887. 
Plethysmograph,  Mosso's,  180 
Plenral 'Effusion,  Seriousness  of,  Re- 
lief by  Massage   and   Rest, 
289. 

-  Fluids,  Effect  on,  of  Respiratory 

Movements,  14. 

Pleurisy,  Pain  of,  Poultices  to 
Relieve,  255. 

-  Severe,  Leeches  for,  257. 
Pleuro-pericardial  Adhesions,  Pulse 

forms  Indicative  of,  178. 
Plexuses.     Cardiac.     68,    (fig.)    54, 
Branches    of    Vagus     going 
to,  67. 

-  Coronary,  63,  (fig.)  54. 
Pneumogastric  Nerve,  see  Vagus. 
Pneumonia,  Bradycardia  after,  167, 

Paroxysmal  Bradycardia  in, 
168. 

-  Poise-tracings  in  (figs.),  183. 
Poiseuille's  Manometer,  15. 
Poisoned  Blood,  see  under  Blood. 
Poisons,  see  also  Toxins,  and  Toxic 

Action  under  Drugs,  &c. 

-  Action  of,  on  Medusae,  86. 

-  in    Blood,   Action    on,    of   Liver, 

354,  395. 

-  Cardiac,  Different  Reaction  to,  of 

Outside  and  Inside  of  Frog's 
Ventricle,  269-71. 

-  Causing    Bradycardia.    and    Par- 

oxysmal Bradycardia,  168. 

-  Collapse  from,  Blood-pressure  Low 

In,  181. 

-  from  Digestive  Products,  394. 

-  Fatty  Degeneration  of  the  Heart 

from,  151. 

-  Paralysis  by,  of  Inhibitory  Vagus 

Fibres,  Effects,  71-2. 

-  from  Plants,  Congeners  to  Digitalis, 

Used  and  Unused,  811. 

-  from  Skin  of  Toads,  311-2. 

Polygraph,  Mackenzie's,  127. 

Portal  System,  Effects  on,  of  Dilata- 
tion by  Ligature,  19 ;  of 
Venous  Engorgement,  223-4. 

Vein,   Effect  on,  of  Irritation  of 
Splanchnic  Nerves,  87. 


Position,  Bodily,  to  Avert  and  Relieve 
Faintness,  ISO,  422. 

—  in  Cerebral  Haemorrhage,  455. 

-  -  in  Nauheim  Exercises,  245,  248. 

-  -  Palpitation  and,  176,  225,  412. 

—  aud  Pulmonary  Murmurs,  216-7. 

—  Pulse-rate  and,  Author's  Experi- 

ments on  Himself,  162. 

-  -  inRestTreatment,234-6,(tfsrs.)285. 

-  -  Sudden  Change  in,  Danger  of,  in 

Aortic    Regurgitation,    405, 


Post-nasal  Catarrh,  Headache  from, 
447. 

-  -  Gastric  Catarrh,  and  Dyspepsia 

from,  890-1. 
Post-partum  Hemorrhage,  Pituitrin 

for,  819. 
Potain's    Sphygmomanometer,    102, 

444,  Mode  of  Use,  107. 

-  -  Combination    of,     with     other 

Instruments  (fig.),  105. 
Potassium,  Counteracted  by  Barium, 
278-9. 

-  Acetate,  as  Diuretic,  350. 

-  Bitartrate,  with  Jalap,  as  Diuretic, 

853. 

-  Bromide,  Sedative  Action  of,  in 

-  -  Graves's  Disease,  416. 

-  -  Headache,  449. 

-  -  Insomnia,  with  Digitalis,  482. 

-  -  Palpitation,  418. 

-  and    Calcium    in   Solution,    with 

Sodium  Chloride,  Perfusion 
with,  as  affecting  Vagus 
Powers,  71. 

-  Carbonate.Solution  of,  for  Pruritus 

ani,  429. 

-  Citrate, in 

-  -  Cerebral  Thrombosis,  456. 

-  -  Early  Treatment  of  Rheumatic 

Fever,  868. 

-  Iodide,  in 

-  -  Aneurism,  for  Pain,  455. 

-  -  Angina,  Variable  Tolerance   of, 

44S-4. 

-  -  Cardiac  Disease,  445. 

-  -  Cerebral  Thrombosis  of  Syphilitic 

Causation,  457. 

—  Insomnia,  Action   on    Carotids, 

864,  482. 

-  -  Pericardial  Effusion,  877. 

—  Stokes-Adams  Disease,  alone,  or 

with  Mercury,  421. 

-  -  Uses    of,   Drawbacks    to,   how 

Overcome,  840-1. 

-  Nitrate  of,  Action  of,  on  Blood- 

pressure,  389. 


INDEX 


Potassium,  Nitrate  of  (cont.) 

-  -  with  Nitrite  of  Sodium,  in  Senile 

Conditions  of  Vessels,  453. 

-  in   Saline  Solution,  Effects  of,  in 

different  proportions,  on  the 
Heart,  285-6. 

-  Salts,  Effects   of,  on    Heart  and 

Vessels,  334. 

-  Tartrate,  as  Diuretic,  350. 
Pouches,  Pulsatile,  on  Frog's  Heart, 

in  Experiments  with  Digi- 
talis, 297. 

Poultices,  Applications  of,  255-7,  263, 
432. 

Prescriptions  of  Carminatives  for 
Irregular  Pulse,  438-9. 

-  to  Disguise    Taste   of   Iodide    of 

Potassium,  341. 

Pre-systolic  Murmur,  indicative  of 
Mitral  Obstruction,  214-5, 
and  of  Mitral  Stenosis,  407. 

Pressure  in  Artificial  Circnlation,Con- 
stant,  causing  (Edema  of 
Tissues ;  Rhythmic,  better 
in  all  ways,  11. 

-  over  Cardiac  Begion  to  Still  Palpi- 

tation, 413. 

-  on  Carotid,  in  relief  of  Migraine, 

185. 

-  External,  Unfelt   by    Heart   and 

Certain  Other  Organs,  186. 

-  Intermittent,  External,  on  Veins, 

as  Aid  to  Circulation,  10. 
Proteins,  Action    on,  of  Digestion, 
355,  386,  398-4. 

-  in  Diet  in  High  [Senile]  Tension, 

452-3. 
Protoplasm,   Living,  Differentiation 

of,  in  relation  to  Contracti- 

bility,  28-30. 
Protoplasmic    Connective    Cells    of 

Heart,  53. 
Pruritus  ani,  as  Cause  of  Insomnia, 

Treatment,  42^-30. 
Pseudo-pulsation    in    Left    Jugular 

Vein.  135-6. 

Pulmonary  Aeration,  Heart's  de- 
pendence on,  151. 

-  Artery(ies)  Action  on, of  Adrenalin, 

334. 

-  -  Circulation  into,  26. 

-  Increased    or    Altered  Pressure 

in,  Second  Sound  with,  211. 

-  Resistance      from,     to      Right 

Ventricle,  78. 

-  Right,Atheromaof,Enectsof,228. 
-  -  Rise  of  Blood-pressure  in,  Extra 

Systole  due  to,  171. 


Pulmonary  (cowt.) 

-  Capillaries,  Collapse  of,  in  Mitral 

Obstruction,  222. 

-  -  Effect  on,  of  Heat  and  Cold,  94. 

-  Cardiac  Murmurs,  possible  Causes 

of,  216-7. 

-  Circulation,  Action  on,  of  Nitrites, 

445. 

-  -  Obstruction  to,  and   Backward 

Pressure  in,  results  of,  222-3, 
228. 

-  Congestion,     in     Aortic     Incom- 

petence, 403. 

-  Engorgement,  Causes,  219. 

-Valves,  and  Aortic  Valves,  Asyn- 
chronous Closing  of,  Effects 
of,  on  Second  Sound,  211. 

—  Contractile  Power  of,  Value  of, 

in  Mitral  Regurgitation,  221. 

-  -  Independent  Pulsation  of,  21-2, 

55,  77-8. 

-  -  Valveless,  221. 

Pulsatile  Pouches,  on  Frog's  Heart, 

in  Contraction,  297. 
Pulsation.  Abdominal,Causes,&c.,  177. 

-  Arterial  (see  also  Self-massage),  177, 

Periodical,  88. 

-  Cardiac,  Effect  on,  of  Stimulation 

of  Vagus  Trunk  and  Centre 
by  Electricity  and  by  Digi- 
talis, 61. 

-  -  as  Exercises  for  the  Arteries,  11. 

-  Rhythmical  Independent,  of  Vena 

Cava  and  Pulmonary  Vein, 
77,  Effects,  78;  Re-discovered 
by  Author  and  Fayrer,  21-2. 

-  Three    Kinds    of,    Observable   in 

Aortic  Regurgitation,  219. 
Pulse,  Amplitude  of,  Modes  of  In- 
creasing Reasons  for,  157-8, 
(/iff.)  157. 

-  Aortic,  Tracing  of,    after  Marey 

(fa.),  124. 

-  -  in  Regurgitation  (fig.),  130. 
-Carotid,  Best  for  timing  Cardiac 

Murmurs,  138. 

-  -  Cardiograms  of,  127. 

—  Comparison  of,  with  Auricular 

Systole,  137,  (fiy.)ib. 

-  -  Sphygmograms  of,  129,  (fig.)1S7, 

-  Changes  in,  Indicative  of 

-  -  Endocarditis,  376. 

—  Rheumatic  Fever,  &c.,  367. 

-  Feeling  by  Finger  Pressure,  100-1, 

114,  119-20,  128-9. 

-  in    Mitral    Regurgitation    to    be 

Noted  after  Running  Up- 
stairs, 409. 


512 


INDEX 


Pulse  (cont.) 

-  Movements   of,    Instruments    for 

Investigating,  125-7. 

-  Normal,  Tracings  from,  (  figs.)  129, 

182,  192. 

-  Pulsus  Paradoxus,  172, 178. 

-  Radial,     in      Bradycardia,      165, 

(fig.)  ib. 

-  -  Pulse-wave  in,  129,  (fig.)  187. 

-  Riegel's,  172, 173. 

-  Senile,  126, 132,0?grs.)126, 133,  184. 

-  In  relation  to  Systolic  and  Dias- 

tolic  Pressures,  115-6. 

-  Venous,  Characters  of,  136-7. 

-  -  Sphygmograms  of,  186,  ( fig.)  187.    I 

—  in  Tricuspid  Regurgitation,  185.     | 

-  Very  Slow,  in  Stokes-Adams  Dls-   I 

ease  (fig.),  169. 
Pulse  (and  Pulse-rate),  Action  on,  of 

-  -  Adrenalin,  276,  815. 

-  -  Atropine,  274. 

-  -  Bleeding,  339. 

-  -  Caffeine,  318. 

-  -  Digitalis,  Medioaland  Toxic,  117, 

(fig.)  ib.,  277,  299,  804-6, 
307,  (figs.)  805,  £  $f.  145, 
318,  376. 

-  -  Drugs,  339. 

-  -  Emotion,  159,  163,  194,  (fig.)  164. 

-  -  Excitement  (fig.),  164. 

-  -  Exercise,  110-11,  (figs.)  Ill,  246. 

—  Extrinsic  Afferent  Nerves,  65. 

-  -  Fever,  94. 

-  -  Heat  and  Cold,  98. 

-  -  Massage  and  Graduated  Move- 

ment, 158,  (figs.)  157,  240. 

-  -  Medulla  Oblongata,  161-2. 

-  -  Nauheim    Baths,    244,  Author's 

Personal  Observations  on, 
249,  (figs.)  246-7. 

-  -  Nicotine,  277,  828-4. 

•  -  Position,  Author's  Personal  Ex- 
periments, 162. 

-  -  Temperature,  162-3. 

-  -  Thyroid  Extract,  90. 
Pulse,  Rate  of 

—  Affections  of,  Causes,  Incidence, 

and  Indications. 

Bigeminal  Pulse,  170-1. 

-  -  Bradycardia,  165-8,  (fig.)  166. 

Paroxysmal,  168. 

Coupled  Beats,  169-70,  (fig.)  171. 

Dichrotic,  &c.,  181,  (fig.)  ib. 

Extra  Systoles,  171-8. 

Feebleness,  64, 158-61,  237. 

Intermittent  and  Regular  Pulse, 

47,  169,220,  222,  487  et  sqq., 

(Kg».)  134,  220. 


Pulse,  Rate  of,  Affections  of  (eont.) 

Stokes-Adams  Syndrome,  168-9, 

(fig.)  169. 

Tachycardia,  168. 

Paroxysmal,  168-4. 

-  -  Alterations    in,    Stimuli  Condi- 

tioning, 72. 

-  -  Common    in    Normal    State    in 

Moderate  Excitement  or 
Slight  Fever,  and  in  Great 
Excitement  or  High  Fever, 
168,  (fig.)  164. 

-  -  Effect  of,  on  Oscillation  of  Ten- 

sion,  116,  (fig.)ib. 

-  -  in  Exophthalmic  Goitre,  165. 

-  -  in  Fever,  163. 

-  -  and  Forced  Work  of  the  Heart,  5. 

-  -  in  Health  and  Disease,  Factors 

of,  161, 163  ft  s<in. 

-  -  Rapid,  Slowing  of,  Importance 

and  Means,  6. 

-  -  Slowness  of,    in    Asphyxia,  18  ; 

after  Childbirth,  167. 

Pulse-pressure,  or  Oscillation  (q.v.), 
115;  Effect  on,  of  Pulse-rate, 
116,  (fig.)  ib.,  and  when 
Slowed  by  Digitalis,  (fig.) 
117;  Significance  of,  118, 
(fig.)  ib. 

Pulse-wave,  Nature  of,  123  et  sqij. 

-  Increased  by  Massage  and   Rest, 

288,  (fig.)  240. 

-  Propagation  of,  Speed  of,  Delay  in, 

187-8. 
"  Pulvis  Mirabilis"  for  Debility,  414, 

Prescription,  489. 
Pupil,  Dilatation  of,  by  Adrenalin, 

815,  by  Atropine,  274. 
Purgation, Free,  to  Remove  Suspected 

Toxins  in  Bradycardia,  420. 
Purgatives,    see    also   Aperients,    & 

under  Names. 

-  Diuretic  Action  of,  352-3. 

-  Gentle,  in   Cerebral   Thrombosis, 

466. 

-  in  Urticaria,  450. 

Purin  Bodies,  as  Cardiac  Stimulants, 
287-8;  Action  of,  317-8; 
Contra-indicated  in  Angina, 
448. 

-  -  Allied  to  Urea,  as  Diuretics,  848, 

349. 
Purkinje's  Experiments  on  the  Heart, 

Diagram  of  (fig.),  155. 
Purkinje's  Fibres,  Nature  of,  28,  57, 

(fig.)  58. 
Pus,  Accumulation  of,   Risks  from, 

452. 


INDEX 


513 


Pylorus,  Action  on,  of 

-  -  Chemical  Stimulation,  388. 

-  -  Mechanical  Stimulation,  389. 

-  Spasm  of,  Causes,  888-90,  (fig.)  390. 

-  Stenosis  of,  Alkalinity  of  Urine  in, 

392. 
Pyorrhwa  alyeolaris,  Causes  of 

-  -  Dyspepsia,  383. 

-  -  Fatal    Ulcerative   Endocarditis, 

383. 

—  Headache,  447. 

Pyramidol,  for  Headache,  448. 

Pyridine  Bases,  from  Tobacco-smok- 
ing, 325. 


QUASSIA,  with  Perchloride  of  Iron,  in 

Cardiac  Pain,  440. 
Quickening  of  Heart  by  Vagus  (q.v.), 

70-3. 

Quiet,  Essential  to  Secure  Sleep,  426.   1 
Quinine,  Action  of,  on  Frog's  Heart,   j 

as    Affected     by    Atropine,   j 

Seasonal  Difference  in,  282. 
-  Effect  on,  of  Iodides,  341. 


RABBITS,  Depressor  Nerve  in,  65. 

-  Ear   of,  Effect    in,  of   Pure   and 

Poisoned  Blood,  Apparatus 
for  Examining,  (Jig.)  271,  272. 

-  Experiment   on,    with    Isopropyl 

Alcohol,  illustrating  action 
of  Circulation  on  Nerve  Cells, 
368. 

-  Experimental  Aortic  Regurgitation 

in,  406. 

-  Hearts  of,  Fatty  Degeneration  in, 

after  Vagus-section,  160. 

-  -  Fibrillation  in.Recovery  from,  63. 

-  -  Nervous  Fibrils  at,  85,  (fig.)  ib. 

-  -  Nceud  Vital  in  (fig.),  62. 

-  -  Stoppage    of,  by    Inhalation    of 

Ammonia  or  Chloroform,  78. 

-  Inhibitory  Power  of  Right  Vagus 

strongest  in,  67. 
Race-differences   in    Human    Blood- 

pressure,  110. 
Radial  Artery,  Effect  on,  of   Cold, 

Locally  Applied,  254. 

-  -  Location  for  Use  of  Sphygmo- 

graph,  128. 

-  -  Pulsation  of,  in  Bradycardia,  165, 


-  -  Pulse-wave     in,     129  ;     Tracing 

(fig.),  137. 

-  -  Rise  of  Tension  in,  from  Oxygen 

Inhalation,  445. 


Rales,  Dry,  and  Moist,  Heard  in 
Lungs,  in  Cardiac  Dyspnoea, 
197. 

Rana  (see  also  Frogs),  Esculenta 
and  Temporaria,  Action  on 
Muscles  of,  of  Caffeine,  284. 

Raynaud's  Disease,  Cause,  Nature, 
Results,  and  Allied  Con- 
ditions, 197-8,  450. 

Recklinghausen's,  von,  Aneroid  In- 
strument for  Measuring 
Diastolic  Pressure,  114-5. 

-  Modification  by,  of  Armlet  Sphyg- 

momanometer,  108, 114-5. 
Recording        Sphygmomanometers, 

Erlanger's,  Gibson's,  Hirsch- 

felder's,  115. 
Recovery,  Natural  Tendency  to,  in 

Heart  Disease,  how  to  assist, 

366-7. 
Rectal  Administration  of  Morphine, 

advantages  of,  486. 

-  Application  of  Lotion,  in  Pruritus 

ani,  429-30. 

Recumbency,  Difficulty  of  Breathing 
in,  Causes,  234. 

-  in  Faintness,  180. 

-  Pulmonary    Murmurs    in,  Causes 

of,  216-7. 

Red  Corpuscles,  Course  of,  in  Body,  9. 
Redness     after    Mustard    Poultice, 

Causes  of,  89. 
Reduplication  of 

-  First  Sound  of  Heart,  Causes  and 

Deductions,  212. 

-  Second  Sound,  Causes,  211. 
Reflex  Stimulation,  see  under  Stimu- 
lation. 

-  Stoppage  of  Heart,  in  Imperfect 

Anaesthesia,  179. 
Reflexes    of    Limbs,    produced    by 

Extrinsic  Afferent  Nerves,  65. 
Refractory  Period ,  or  Rest,  or  Sleep  of 

the  Heart,  4,  6, 42  e«  8^.,  271. 

-  Discovered     by     Kronecker     and 

Marey,  44. 

-  in  Frog,  44-5. 

Regulating  Action  of  the  Arteries,  7,  8, 

known  to  Harvey,  7. 
Regulation  of  Blood-pressure,  Factors 

of,  7-8, 16, 17,  20,21,64.94,172. 
Regurgitation,  see  also  Aortic,  Mitral, 

«£•  Tricuspid. 
-Cardiac   Murmurs    from,    Causes 

and  Indications,  214,  215. 

-  Caused  by  Feeble  Cardiac  Contrac- 

tion,   even     with    Healthy 
Valves,  75,  ( fig.)  ib. 


INDEX 


Regurgitation  (cant.) 

-  Lessened  by  Digitalis,  309. 

-  Prevention  of,  in  Normal  Contrac- 

tion of  Heart,  55. 

-  Valves  of  the  Heart  Preventing,  78. 
Kemak's    Ganglion,    Frog's    Heart, 

26,  56 ;  Effect  of  Stimulating, 
on  Inhibition,  40 ;  and  Origin 
of  Stimuli  in  Frog's  Heart,  30. 

Remedies,  see  Drugs  <£•  Treatment,  see 
also  Cardiac  and  Vascular 
Remedies. 

Renal,  see  also  Kidneys,  Urinary,  ct 
Urine. 

-  Affections,  Chronic,  Cardiac  Weak- 

ness of,  Gallop  Rhythm  indi- 
cative of,  212. 

-  Artery,  Blood  from,  Distribution 

of,    in    Kidney,    Mechanism 
regulating,  347-8,  (fig.)  148. 
-  -  Ligature  ofjEffects  on  Urine,  simi- 
lar to  that  of  Digitalis,  807. 

-  Blood-vessels,  Action  on,  of 

-  -  Caffeine,  818. 

-  -  Digitalis    Group,    according    to 

Dosage,  335. 

-  -  Strychnine,  835. 

-  Circulation,  347-8,  (figs.)  848. 

-  -  Action  on,  of 

Digitalis,  308,  309-10. 

Diuretics,  348  et  tqq. 

Pituitary  Secretion  and  Ex- 
tract, 90,  819. 

-  Disease,  Hippuric  Acid  converted 

into  Benzoic  Acid  in  the 
Body  (Schmiedeberg,  Jaars- 
veld  &  Stokvis),  91  n. 

-  -  Removal  in,  of  part  of  Kidney, 

Effect  of,  on  Blood-pressure, 
91. 

-  Glomeruli,  Function  of,  in  Urine 

Excretion,  346-7. 

-  Tubules,    Function   of,    in  Urine 

Excretion,  347. 

-  -  Senile,  Invaded  by  Macrophags 

(fig.),  208. 

Rennin,  in  Pepsin  Preparations,  888. 

Resinol  Ointment,  for  Pruritus  ani, 
430. 

Respiration  (tee  also  Inspiration), 
Altered  Pressure  in  Pul- 
monary Artery  at  End  of, 
and  the  Second  Sound,  211. 

-  Arrest  of,  by  Pricking  Nceud  Vital 

of  Medulla,  61-2. 

-  Artificial,  with  Oxypen,  When  and 

How  Performed,  248,  (fig.)  ib. 

-  and  Cardiac  Dyspnoea,  196. 


Respiration  (cont.) 

-  Effect  on,  of  Exercises  as  Gauge 

of  Functional  Capacity  of 
Heart,  216. 

-  -  of  Extrinsic  Afferent  Nerves,  65.      ( 

-  in  MitralRegurgitation.tobe  Noted 

after  Running  Upstairs,  409. 

-  Movements  of,  Effect  of,  on  Pleural 

and  Peritoneal  Fluids,  14. 
Respiratory  Centre,    Action    on,    of 
Opium,    now   Counteracted, 
364. 

-  -  of  Poisonous  Doses  of  Digitalis, 

298. 

-  Movements,  Effect  of,  on  Pleural 

and  Peritoneal  Fluids,  14. 

-  -  Instruments  for  Registering,  127. 

-  Passages,     Irritation    of,     Reflex 

Stimulation  of  Vagi,  and 
Heart  Stoppage  from,  73. 

-  Rhythm,  Origin  of,  27. 

Rest,  Angina  Pain  Quiescent  in,  190. 

-  in  Cerebral  Haemorrhage,  455. 

-  in  Cerebral  Thrombosis,  456-7. 

-  after  Meals,  in  Angina  Pectoris,444. 

-  In    Heart   Disease,   Duration    ad- 

vised, of.  869,  Value  of,  Warn- 
ing on,  866. 

-  Lack  of,  in  Modern  Treatment  of 

Rheumatic  Fever,  Influenza, 
&c.,  as  Affecting  the  Heart, 
868-9 

-  as  Means  of  Slowing  Pulse-rate,  6. 

-  Arrangements  in,  for  Evacuations, 

284-6 

-  Graduated       Exercises       daring, 

289-40. 

-  Massage  during,  Use  of,  236,  Com- 

bined Effects  of  Rest  and 
Massage,  237-9. 

-  Position  in,  234-5. 

Rest,  ABSOLUTE,  in  Treatment  of 
Cardiac  Disease,  Author's 
Definition  of,  and  Insistence 
on,  232-4. 

-  -  in  Endocarditis,  869,  378. 
—  in  Pericarditis,  Septic,  378. 

-  -  Rules  Regarding,  233-4. 

-  in  Bed,  Prolonged,  best  Cure  for 

Graves's  Disease,  415. 
Rest  or  Sleep  of  Heart,  see  Refractory 

Period. 
Restlessness    of    Graves's    Disease, 

Treatment,  416. 
Rheumatism     and     Cardiac     Pain, 

Treatment,  440. 

-  Acute,  Bra'lycardia  in,  and  after, 

167, 168. 


INDEX 


Rheumatism,  Acute  (cent.) 

—  Inflamed  Joints  in,  Blisters  for, 

264. 

-  -  Local  and  Medicinal  Treatment, 

374-6. 

Rheumatic  Fever,  Acute  Heart 
Diseases  Occurring  during, 
Attention  to  Signs  of,  367. 

-  -  Bigeminal  Pulse  from,  170. 

-  -  Clothing  and  Bed-clothes  for,  370. 

—  Diet  in 

Drinks  for,  878. 

Febrile  Stage,  872-8. 

Post-febrile  Stage,  873. 

—  Endocarditis    Associated    with, 

151. 

-  -  Evacuations    in,    Arrangements 

for,  370 

-  -  Irregular  Pulse  Subsequent  to, 

170. 

-  -  Modern  Treatment  of,  in  relation 

to  Heart  Disease,  868. 

—  Salicin  Compounds  in,  263. 

-  -  Stimulants  in,  873-4. 

—  Temperature  in,  Keeping  Down 

of,  Sponging  to  Secure,  370-1. 

-  Tendency,  Associated  with    Ray- 

naud's   Disease,   Treatment, 

450. 
Rhubarb,    in    Senile   Conditions    of 

Blood-vessels,  453. 

Rhythm,  see  Cardiac,  Gallop,  it  Nodal. 
Rhythmical  Contractions    in    Veins 

and  Vessels,  88,  222. 

-  -  in  Voluntary  Muscle,  how   In- 

duced, 38  n. 

-  Pressure   (se«  also  Pulsation),  in 

Artificial  Circulation,  Ad- 
vantages of,  11. 

Riegel's  Pulse,  172-3. 

Right  Side,  Lying  on,  Effect  of,  on 
Heart,  176. 

Ringer's  Solution,  and  Discovery  con- 
cerning Tap-water,  285. 

-  -  Contractionin,ofStrips  of  Artery, 

how  Effected  by,  289. 

-  -  Use  of,  in  Artificial  Circulation, 

273. 
Riva    Rocci's    Sphygmomanometer, 

104,  Fallaciesof,108,  Author's 

Method  of  Using,  105. 
Rosmarini,  Oleum  and  Spiritus,  as 

Carminatives,  860. 
Rotator   Muscles    of    the    Leg,    as 

Accessory     to     Circulation, 

12,  286-7. 
Rowing-machine,for  Cardiac  Patients, 

252. 


Roy's  Manometer,  96. 

Rubbing  and  Cold  Water,  Dilatation 

of  Vessels  from,  more  Lasting 

than  from  Immersion  of  Feet 

in  Hot  Water,  427. 
Running  at  the  Nose  from   Iodides, 

342. 

-  Quick,  Imitation  of,  on  one  Spot, 

as  Test  in  Mitral  Regurgita- 
tion,  409. 

-  Upstairs,    Effects    on    Pulse   and 

Respiration,  in  Mitral  Re- 
gurgitation,  409. 

Rupture  of  Cerebral  Blood-vessel, 
202,  Death  from,  in  High 
Tension,  452 ;  Treatment, 
455. 

S.A  NODE,  see  Sino-Auricular. 
Saccharin,  to  Mask  Taste  of  Iodides, 

341. 
Sahli's  Sphygmomanometer,  102. 

-  Sphygmoboloraeter,  114. 
Sajpdin,  in  Angina  Pectoris,  444. 
Salicin  Compounds,  Treatment  by,  of 

Rheumatic    Fever,    263,   as 
affecting  Heart  Disease,  868, 
369. 
Sal  icy  late  of 

-  Methyl,  in  Rayuaud's  Disease,  450. 

-  Soda,    for    Headache,    448 ;     the 

Remedy  for  Pains  of  Acute 
Rheumatism,  374,  Adjuncts 
to,  374-5. 

-  -  and  Aromatic  Spirits  of  Ammonia, 

in  Acute  Rheumatism,  374. 

-  -  and  Bromide,  in  Raynand's  Dig- 

ease,  450. 

Salicylates,  in  Cardiac  Pain,  440. 

Salicylic  lonization,  for  Pericarditis 
Pain,  377. 

Saline  Solution  and  Calcium  alone, 
Effect  on  Heart,  285,  with 
Calcium  and  Potassium, 
Effects  on  Heart,  285-6. 

—  Different  Effects,  when  made  with 
Tap-,  and  with  Distilled 
Water,  Ringer's  Discovery, 
285. 

-  -  Effects  on  Frog's  Heart,  285. 

-  -  Glucose   in,    Effect   of,    Locke's 

Experiments,  287. 

-  -  in  KymograpliicObservations,96. 
Salines,  as  Adjunct  to  Mercury  in 

Elimination  of  Bile  and 
Toxins,  355. 

-  for  Bed-bound  RheumaticPatients, 

Mixture  with,  875. 


5i6 


INDEX 


Salines  (con.t.) 

-  as  Diuretics,  350. 

-  for  Headache,  447,  448. 

-  Mercurial,  in  Bradycardia,  420. 

-  in   Senile    Conditions    of    Blood- 

vessels, 453. 
Saliva,  Digestive  Action,  384,  386. 

-  Secretion,  &c. ,  of 

-  -  Action  on,  of 
Adrenalin,  315. 

Iodide     of      Potassium      and 

Sodium,  340-2. 

Mastication,  340-2. 

Mercury,  350-1. 

Salol.    as     Intestinal    Disinfectant, 

859-60. 
Salt,  Common,  in  Graves's  Disease, 

415. 

-  -  Solution    of,    Etfects   on    Frog's 

Heart,  285. 

-  -  with  Milk  Diet    in    Rheumatic 

Fever,  872. 
Salts,    Inorganic,  Effect   on  Heart, 

285-6. 

Sal  Volatile,  in  Stomach  Acidity,  357. 
Sartorius  Muscle,  Frog's  Leg,  Excita- 
tion of,  when  Motor  Nerve 

Inactive,  29. 
Sassy     Bark,     see     Erythrophlceum 

guineente. 
Scalfati's    Experiments    on     Fatty 

Heart  in  Dogs,  314. 
Scaling  of  Teeth  in  Pyorrhoea,  383. 
Schema  of  Circulation,  94-5,  (/?<?.)  95. 
Schott,  August  aud  Theodore,  Nau- 

heim  Treatment  devised  by, 

243-4. 
Schott,  Theodore,  Dietetic  Rules  of, 

for  Cardiac  Disease,  250-1. 
Sciatic  Nerve,  Irritation  of,  Effect  on 

Superficial    Veins    of    Hind 

Legs,  87. 
Scillain,  Action  of,  on  Outside  and 

on  Inside  of  Frog's  Ventricle, 

270. 
Sclerosis  (see  also  Arterial)  of 

-  Carotids,   as   Cause   of  Sleepless- 

ness, 364. 

-  -  Reduction  of,  Various   Methods 

for,  364. 

-  Coronary     Arteries,     Paroxysmal 

Bradycardia  in,  168. 

Seasonal  Modification  of  Drug  Action, 
281-2. 

Secretin,  Passage  of,  into  Blood,  and 
Action  on  Pancreas,  393. 

Secreting  Cells  in  Kidneys,  Drug- 
action  on,  346  et  tqq. 


Secretions 

-  of  Bile,  395. 

-  of  Ductless  Glands,  Action  of,  on 

Tissue-metabolism,  381. 

-  External  and  Internal,  391-3. 

-  Internal,  discovery  of,  by  Bernard, 

89. 

-  of  Urine,  Ludwig's  and  Bowman's 

Theories  of,  346-7. 

Sedative  Action  of  Tobacco-smoking, 
826-7. 

-  Ointment  for  Cardiac  Pain,  441. 
Sedatives 

-  in  Aortic  Stenosis,  403 

-  in  Graves's  Disease,  416. 

-  Local  Gastric,  Hydrocyanic  Acid, 

Dilute,  in  Paroxysmal  Tachy- 
cardia, 419. 

-  for  Mental  Excitement  and  Irrita- 

tion, In  Palpitation,  413. 
Selective  Action  of  Drugs,  273,  274-5. 
Self  Massage  of 

-  Arteries,  10-11, 156-7, (figs.)  10, 156. 

-  -  Action  on,  of 
Digitalis,  309. 

Massage  and  Exercises,  240. 

Massage  and  Rest,  288. 

-  Heart. 

-  -  Action  on,  of 
Digitalis,  308. 

Massage    and   Exercises,    240, 

(Jig-)  «&• 
Massage  and  Rest,  238. 

-  -  Oxygen  Inhalation,  241. 

-  -  in  relation  to  Nutrition,  154-5. 
Senile  Conditions   of  Blood-vessels, 

Treatment,  452  et  gqq. 

-  Decay. 

—  Causes  of,  Actual,  Secondary  ,202, 
Primary,  Author's  view,  204. 

Metchnikoff's  views  on,  203-4. 

(figs.)  203. 

--Deaths from,  202. 

-  -  How  to  Avert,  454. 

-  Gangrene,  Causes,  204. 

-  Pulse,  126, 132,  (figs.)  126, 183, 134, 

-  Rise   of    Blood-pressure,    Causes, 

201-2. 

Senna,  as  Eliminant,  375. 
Sensation,  Production  of,  by  Extrinsic 

Afferent  Nerves,  65. 
Sensitiveness  of  Arteries,  184-5,  and 

Heart,  186-7. 
Sensory  Affections,  from  Rupture  of 

Cerebral  Vessel,  202. 

-  Nerves,    Stimulation    of,    Reflex 

Stimulation  of  Vagus  from, 
167. 


INDEX 


Si? 


Sensory  Nerves  (coat.) 
—  of  Heart,  64-5,  Intrinsic  Func- 
tions of,  53-4. 

-  -  of  Special  Senses,  affecting  Pulse- 

rate,  72. 

-  Phenomena,  Functional,  185-6. 
Septic  Endocarditis,  and  Pericarditis, 

sec  under  Endocarditis,  and 
Pericarditis. 

Septum,  Inter-Ventricular,  Nerve- 
fibres  along,  62;  Puncture 
of,  Effects  of,  61-3. 

Serotherapy,  an  Anticipation  of,  in 
Blister-treatment  of  Rheu- 
matic Joint  Pains,  375-6. 

Serous  Effusion,  Effect  on,  of  Mas- 
sage and  Best,  237,  239. 

-  -  Pericardial,    Blisters    to    cause 

Absorption  of,  263. 

Serum,  Experiments  with,  on  Frog's 
Heart,  284-5. 

Serum  Albumen,  as  Cardiac  Nutrient, 
286. 

Sex-incidence  of  Bradycardia,  167 ;  of 
Fainting  in  Hot  Rooms,  181. 

Sex- variation,  in  Human  Blood- 
pressure,  110;  in  Pulse-rate 
in  sitting  position,  162. 

Sexual  Organs,  Reflex  Stimulation 
from,  of  Vagus,  Bradycardia 
due  to,  167. 

Sharpey,  Prof.,  Digitalis  Investiga- 
tions suggested  by,  296. 

Sheath  of  Arteries  and  Veins,  Lym- 
phatic Vessels  with,  10, 156-7, 
(Jigs.)  10, 156. 

Sheep,  Blood-pressure  in,  96. 

-  Heart  of,  Purkinje's  Fibres  from 

(fig-),  58. 

Shellfish,  as  Cause  of  Urticaria,  450. 
Shingles,    Cardiac    Pain    associated 

with,  Treatment,  441. 
Shock. 

-  Avoidance  of,  by  Complete  Anaes- 

thesia, 424. 

-  Blood-pressure  Low  in,  181. 

-  Effect  of,  on  Heart  and  Vessels, 

177  et  sqq. 

-  -  from  Gastric  Disturbance,  179. 

-  -  Goltz's  Experiment  with,  178-9, 

(fig.)  178. 

-  -  in  Surgery,  179. 

-  Electric,  in  Fibrillation  of  Dog's 

Heart,  63. 

-  Measures  in  relief  of,  424. 

-  -  Adrenalin  Valuable,  815. 

-  -  Pituitnn     in,    424,    How   Best 

Given,  320. 


Shock  (tout.) 

-  and  Syncope,  Difference  between, 

180. 

Shortness  of  Breath  (gee  also  Cardiac 
Dyspnoea),  in 

-  -  Aortic  Disease,  403. 

-  -  Mitral  Regurgitation,  Treatment, 

409. 

Sick  Headache,  see  Migraine. 
Sight,  in  Faintness,  421-2. 
Sigmoid  Valves,  Function  of  (  fig.),  6. 
Sino- Auricular,  or  S.A.  Node. 

-  Pacemaker  of  Heart,  58,  72. 

-  Position,  57. 

Sinuses,  Nasal,  Inflammation  of, 
Cause  of  Headache,  447. 

Sipping  of  Carminative  of  Bicarbonate 
Soda  and  Peppermint  Water, 
439. 

-  of  Water,  not  Gulping  Down,  Im- 

portance of,  385. 
Sitting  Posture,  Pulse-rate  in,  Sex- 

variation  in,  162. 
Sitting-up  in    Treatment   by   Rest, 

Rules  for,  234-5. 
Size  of  Blood-vessels,  Measurement 

of,  Instrument  for,  118-9. 
Skeletal  Muscles,  Contractile  Power 

of,  Source  of,  150. 
Skiagrams  of  Heart,  How  Obtained, 

138-9. 
Skin,  Ansesthetics  for,  in  Tapping  for 

Ascites,  261. 

-  Blood-vessels  of,  Contraction  and 

Dilatation  of,  7,  8,  18,  20. 

-  Blueness  of,  How  Caused,  198. 

-  Bronzed,    in    Addison's    Disease, 

Cause,  90. 

-  Discoloration  of,  from   Disease  of 

Cortical   Portion  of  Supra- 
renal Gland,  289-90. 

-  Reflex  Stimulation  from,  of  Vagus, 

Bradycardia  from,  167. 

-  as  Vascular  Area,  19. 

-  Whiteness  or  Pallor  of,  Indications 

of,  7,  8,  20,  197-8,  219,  401. 
Sleep,  see  also  Insomnia. 

-  Arrangements   to   Secure,   426  et 

tqq. 

-  Mechanism,    Process   of,    Theory 

of,  200,  863,  425. 

-  Natural,  Lessened  Cerebral  Ten- 

sion in,  200. 

-  Tiredness,  Excessive  and  Simple, 

in  Relation  to,  433. 

-  and  Waking,  Alternation  of.Theory 

of,  363. 

-  Warm  Food  to  Induce,  431. 


5i8 


INDEX 


Slowing  of  Heart  by 

-  -  Aconite,  829,  889. 

-  -  Digitalis,  Traube's  Discoveries, 

295. 

-  -  Gastric  Irritation,  73. 

-  -  Nicotine,  828-4. 

-  -  Vagus,  70-3,  324. 

-  -  Venous  Sinus,  8timulationof,324. 
Smelling-salts,  for  Faintness,  422. 
Smells,  Unpleasant,  Abolition  of,  to 

Secure  Sleep,  426. 
Smoking  of  Tobacco,  Effects,  181,  182, 

325-8. 
Snuff-taking,  Nicotine  Absorbed  by, 

325. 
Sodium. 

-  Benzoate,  in  Septic  Endocarditis 

and  Pericarditis,  378. 

-  Bicarbonate. 

—  in  Carminative  Compounds  for 

Pulse-irregularity,  361, 488-9. 

—  in  Dyspepsia,  Efficiency  of,  387. 

-  -  with  Milk  in  Rheumatic  Fever 

Diet,  872. 

—  Mouthwash  of,  with  Laudanum, 

for  Aching  Teeth,  426. 

—  in     Paroxysmal      Tachycardia, 

When  Indicated,  419. 

-  -  for  Pruritus  aui,  in  Solution,  429. 

-  -  for  Stomach  Acidity,  How  Best 

Given,  856-7. 

-  Bromide  of,  in  Graves's  Disease, 41 6. 

-  -  in  Insomnia,  with  Digitalis,  432. 

-  -  in  Palpitation,  413. 

-  -  in  Raynaud's  Disease,  450. 

-  Carbonate,  Addition  of,  to  Saline 

Solution,  Effects,  285. 

-  Chloride,.in  Mucous  Membrane,  39. 

-  -  Solution,  Cardiac  Perfusion  with, 

Effect  on  Vagus  Action,  7. 

-  Hippurates,    in  Angina  Pectoris, 

Action  of,  443. 

-  Iodide,    Use   of;    Drawbacks   to, 

How  Overcome,  840-1. 

-  Nitrite,  as  Diuretic,  850. 

-  -  as  Vaso-dilator,  838,  339. 

in  Aortic  Regurgitation,  406. 

in  Senile  Conditions  of  Blood- 
vessels, 453. 

-  Salicylate,  for  Headache,  448. 

-  -  the  Remedy  for  Pains  of  Acute 

Rheumatism,  374,  Adjuncts 
to,  374-5. 

—  with  Aromatic  Spirits  of  Ammo- 

nia in  AcuteRbeumatism,  874. 

-  Sulphate,  as  Diuretic,  850. 

-  Sulpho-carbolate,       as       Gastric 

Antiseptic,  356. 


Sodium  (conl.) 

-  and  Theobromine,  Synthetic  Com- 

pounds of,  Diuretic  Uses  of, 
818-9. 

Solids  and  Fluids  in  Diet  of  Cardiac 
Disease,  Best  taken  Separ- 
ately, 855,  374,  884. 

Soporific  and  Convulsant  Alkaloids 
in  Opium,  278. 

8oporiflcs,«««  Hypnotics,  &  Narcotics. 

Sounds  of  the  Heart,  see  alto  Cardiac 
Murmurs. 

—  Associated  with  Diastolic  Pres- 

sure, 118. 

—  First,  Alterations  in,  212  e< sqq.,io 

be  Heeded  during  Rheumatic 
Fever,  867. 
Causation,  76-7. 

-  -  How  Caused,  75,  76-7. 

-  -  How  Observed,  75-6. 

—  Nature   and    Factors    of,    76-7, 

(ftgi.)n. 

-  -  Second,  Alteration  in,  210-12. 
Causation,  76. 

Where  Loudest,  77. 

-  -  Third,  Occasional,  77. 

Gallop  Rhythm  Due  to,  211 

Cause,  and  Prognosis,  212. 

-  Soporific  and  Otherwise,  426. 
Soup,  Beginning  Meals  with,  Correct- 
ness of,  387. 

-  in  Cerebral  Thrombosis  457. 
Sour  Milk  Diet,  for  Flatulence,  357-9. 
Spasm  of  Coronary  Arteries  in  False 

Angina,  193. 

-  of  Pylorus,  see  under  Pylorus. 

-  of  Temporal  Arteries,  in  Migraine 

(fig.),  184. 

Spasmodic  Asthma,  seeunder  Asthma. 

Sphincters,  Inhibition  of,  by  Adre- 
nalin, 815. 

Sphygmobolometer,  of  Sahli,  102, 
114. 

Sphygmonrams,  Character  of,  in 
Healthy  People,  129,  (figt.) 
129,  185. 

-  Crochets  or  Hooks  in,  Cause  and 

Meaning,  127,  130,  (fig.)ib. 

-  Deductions  to  be  made  from,  129 

et  tqq.,  (figs.)ib. 

-  Fallacies  in,  132-5,  (figs.)  133, 134. 

-  Inverted,  135,  (fig.)  ib. 
Sphygmographs,  see  Dudgeon's,  Jac- 

quet's,  Kronecker's,  Mac- 
kenzie's, Marey's. 

-  Principle,  Forms,  and   Uses,  126 

et  tqq.,  182,  185,  Author's 
Modification,  128. 


INDEX 


519 


Sphygtnonianumeters.      Method     of 
Using,  107. 

-  Principle  of,  101. 

-  Two  Classes  of,  101  et  sqq. 

-  Various  Forms  of,see  alto  Sphygmo- 

bolometer. 

-  -  Aneroid,  104, 114,  Standardisation 

of,  105,  Author's  Apparatus 
for,  (fig.)  106. 

-  -  Armlet,   104,  107 ;   Fallacies  of, 

108-9. 

-  -  Band,  102, 103. 

-  -  Bulb,  102-3, 104-6,  Mode  of  Using, 

Fallacies  in,  107. 

-  -  Devised  by 

Gaertner,  108,  (fig.)  104. 

Hill,  102. 

Hill  and  Barnard,  104. 

Martin,  105. 

Oliver,  102,  114. 

Potain,  102,  107,  445,  (fig.)  105. 

Biva  Rocci,  104,  108,  Author's 

Mode  of  Using,  105,  (fig.)  ib. 

Sahli,  102,  114. 

von  Basch,  101,  102. 

—  Recording,  of  Erlanger,  Hirsch- 

felder,  and  Gibson,  115. 
Sphygmometer,  Oliver's,  102, 114. 
Spinal  Cord,  Action  on,  of  Antipyrin, 

444. 

-  Vase-motor  and  other  Centres  in, 

85,  Reflex  Irritability  of,  In- 
creased by  Strychnine,  316. 

Spirits,  as  Carminatives,  860. 

Splanchnic  Area. 

-  Arteries  and  Blood-vessels  of 

—  Action  on,  of 

Adrenalin,  333. 

Camphor,  335. 

Digitalis,  306. 

Strychnine,  335. 

-  -  Blood-pressure  Regulation  by,  19, 

333. 

—  Contraction  of,  when  Cutaneous 

Vessels  Dilate,  20;  Dilatation 
of,  in  relation  to  Faintness, 
181. 

—  Vaso-constrictors    affecting  (see 

also  Digitalis),  306. 

-  Nerve,  Action  on,  of  Adrenalin, 

Results    of,    315,   Irritation 

of,  Effect  on  Portal  Vein,  87. 
Sponging,    When    Beneficial,    370-1, 

376,  422,  428-9. 
Sports  for  Cardiac  Patients,  Rules 

for,  251-2. 
Squill  (Vrginea   Scilla),  In  Cardiac 

Disease,  311,445. 


Stairs,  Going  Up  and  Down,  Strain 
of,  on  Heart,  232-3,  407. 

Standardisation  of  Aneroid  Sphygmo- 
mauometers,  105,  Author's 
Apparatus  for  (fig.),  106. 

Standstill  of  Heart,  in 

-  -  Diastole,  Causes,  71,  270. 

-  -  Systole,  Causes,  71,  270,  296,  293. 
Stannius's  Ligatures,  Effect  of  Apply- 
ing to  Frog's  Heart,  31, 40-2, 
(figs.)  41. 

Stasis,  see  Venous  Stasis. 

Static  Electricity,  for  Cardiac  Pain, 

441. 

Stenosis,  see  Aortic,  <£•  Mitral. 
Stethoscope,    for    Auscultation     of 

Heart  Sounds,  76. 

-  in     Measurement     of     Diastolic 

Pressure,  113. 

Stimulants,  Cardiac,  and  Cardiac 
Tonics,  284,  285,  287-8,  295 
et  sqq. 

-  -  in  Endocarditis,  376,  377. 

-  -  Powerful,  in  Paroxysmal  Tachy- 

cardia, 418. 

-  for    Rheumatic    Fever   Patients, 

373-4. 

Stimulating  Action  of  Various  Drugs, 
Processes  and  Probable  Pro- 
cesses of,  316  et  sqq. 

Stimulation  (see  also  Electrical,  Frog, 
Irritation)  of 

-  Accelerator  Nerves,  Effects,  71-2. 
-Auricle,    Effects,  44-6,  (fig.)   45; 

Constant  in  Mitral  Obstruc- 
tion, Results,  220,  222. 

-  Blood-vessels,  from  Within,  89,  and 

from  Without,  Effects,  88-9. 

-  -  Local  Effects.  87. 

-  Brain,  from  Tobacco-smoking,  326. 

-  Eliminating  Organs,  Means  for,898. 

-  Heart,  by  Accelerator  Nerves,  71-2. 

-  -  Effects  of,  56. 

-  -  Forms  Causing  Fibrillation,  63. 

-  -  by  Vagus  Nerve,  70-3. 

-  Muscles,  Effect  on  Arteries  Con- 

nected, 397. 

-  Nerves,  Opposing  Action  Induced 

by,  85-6. 

-  Pericardium,  Extra  Systole  from, 

in  Dogs'  Hearts,  65. 

-  Pylorus,  Two  Modes  of,  888-9. 

-  Reflex,  of  Cardiac  Nerves,  Action 

of,  on  Pulse,  438. 

-  -  of   Inhibitory   and    Accelerator 

Nerves  of  Heart,  72-8. 

-  -  to  Vagus,  from  Stomach,  Paroxys- 

mal Bradycardia  from,  168. 


520 


INDEX 


Stimulation  of  (eont.) 

-  Submaxillary  Gland,  Effect,  897. 

-  Vagus,    E fleets   on    Auricles   and 

Ventricles,  65-6. 

-  -  Central,    and     Reflex,    Causing 

Bradycardia,  166  et  Hf/. 

-  Electrocardiogram  during  (Jig.), 

145. 

-  Vagus  Trunk,  Action  on   Heart, 

Exceptions  to,  71-2. 

-  Possible  Consequences,  07,  (fig.) 

800. 

-  Venous    Sinus,    45-6,    Effects    of 

(fig-),  45. 
Stimuli,  Blocking  of,  36  et  *<iq. 

-  in  Frog's   Heart,  Conduction  of, 

27,  31 ;  Origin  or  Conversion 
of,  80-1. 

-  to  Mammalian   Heart,  Origin    of, 

Nodes,  56. 

-  Reaction    to,    of    Brain-cells,    in 

Relation  to  Insomnia,  425. 

-  Rhythmic,  Origination  »nd  Con- 

duction of,  and  Response  to, 
by  Vagi,  68,  (fig.)  69. 

-  Transmission    of,    through     A-V 

Bundle,  Possible  Mode  of  ,286. 

-  to  Ventricle,  Conduction  of,  161. 
Stimulus  from  Auricle  to  Ventricle 

(Frog's  Heart),  Effect  on,  of 
Stimulation  of  Vagi,  88, 
39-40, 145,  (figs.)  48,  145. 

Stokes-Adams  Syndrome,  Disease, 
Nature,  Causes,  and  Treat- 
ment, 168-9,  421,  (fig.)  169. 

Stomach,  see  also  Abdomen. 

-  Acidity   of,   a   Cause   of  Cardiac 

Irregularity,  882. 

-  -  Alkalies  to  Deal  with,  856-7. 

-  -  Attention  to,  in  Insomnia,  431. 

-  Chemical  Changes  in,  during  Secre- 

tion, 391-2,  (fig.)  892. 

-  Circulation  through,  Bettered  by 

Digitalis,  311. 

-  Congestion  of,  Diminished  by  Mas- 

sage and  Rest,  238. 

-  Digestion  in,  Effective,  as  Preven- 

tive of  Toxin-,  or  Flatulence- 
formation,  355. 

-  Dilatation  or  Distention  of 

-  -  Flatulent,  Effect  of,  on  Heart, 

176, 189,  224,  225 et  sgq. ,(figs.) 
226,  858. 

-  -  Reflex  Stimulation  by,  of  Vagus, 

Effects  on  Heart,  78. 

-  Effect  on,  of  Disordered  Circula- 

tion, 229. 

-  -of  Emotion,  158. 


Stomach  (cont.) 

-  Fermentation     in,     Death    from, 

226-7,  (fig.)  227. 

-  Gases  in  (see  also  in  Intestines), 

860,  374. 

-"Headache"     in     (Angina     Ab- 
dominis),  195. 

-  Inhibition  of,  by  Adrenalin,  815. 

-  Irritation     of,    Causes,    Results, 

Treatment,  356,  488. 

-  Motor    Activity,    or     Peristaltic 

Movements  of,  as  Factor  in 
Gastricl)igestion,887;  Stimu- 
lated by  Bitters,  &c.,  888. 

-  Nerves    of,    in   Relation    to    Par- 

oxysmal Tachycardia,  164. 

-  Normal  Position  of  Heart  -in  Re- 

lation to,  225. 

-  Pain    Unfelt    by,    from    External 

Pressure,  but  felt  from  In- 
ternal Distention,  186. 

-  Reflex  Stimulation  from,  of  Vagus, 

Bradycardia  from,  167,  168, 
Treatment  420;  Paroxysmal 
Tachycardia  from,  419. 

-  Wall  of,  Action  on,  of  Carbonates 

audBicarbpnates  of  Soda, 887. 

-  Warm  Applications  to,  for  Faint- 

ness,  423. 

-  Warmth  to  Inside  of,  to  Induce 

Sleep,  255. 
Stool,  Straining  at,  to  be  Avoided  in 

Cardiac  Disease,  396 ;  Death 

from,  228. 
Stopcock   for   Artificial  Respiration 

with  Oxygen,  243,  (fig.)ib. 
Stoppage  of  Auricle  by  Vagus,  69. 

-  of  Heart,  see  Heart,  Arrest  of,  and 

Heart-block. 

-  of  Ventricle  by  Vagus,  68. 
Storage,  Action  of  Aorta  and  Arteries, 

7. 
Strain,  Cardiac.  Dilatation  from,  217. 

-  Sudden,  to  be  Avoided  by  Cardiac 

Patients,  252. 

-  Tachycardia  from,  417. 
Straining  at  Stool  to  be  Avoided  in 

Cardiac  Disease,  396;  Death 

from,  228. 
Stretching  of  Body,  Action  during, 

of  Limb-Fasciae    on  Venous 

Circulation,  11-12. 
String  Galvanometer,  of  Einthoven, 

Nature  and  Use  of,  189  &  n., 

140-1,  (fig.)  142. 
Stroking  in  Insomnia,  429. 
Strontium.    Bromide,    in    Graves's 

Disease,  416. 


INDEX 


52F 


StropJianthus  hi*pidus,  311. 

-  Action  of,  Chiefly  on  Heart,  312. 

—  in  Aortic  Regurgitation,  407. 

—  in  Cardiac  Asthma,  445. 

-  -  as  Cardiac  Nutrient  as  well  as 

Stimulant,  155-6. 

-  -  in  Fatty  Heart  in  Dogs,  314. 

-  -  on  Frog's  Ventricle,  270. 

-  -  in  Intervalsof  Paroxysmal  Tachy- 

cardia, 418. 

-  -  in  Irregular  Pulse,  438. 

-  -  in  Mitral  Regurgitation,  409. 

-  -  in  Palpitation,  413. 

-  in  Combination  with  the  Diuretics 

Group,  319. 

-  and  Nitro-glycerine  for  Chilblains 

of  the  Elderly,  450. 

-  Poisoning  by,  Mitral  Regurgitant 

Murmur  after,  217. 
Strychnine,  a  pure  Couvulsant,  270. 

-  Action  of,  on 

-  -  Heart,  816-7,  438. 

Nutrient  as  well  as  Stimulant, 

155-6,  377. 

—  Medusa,  86. 

—  on  Nerves,  Myogenic  Theory  as 

Affecting  Use  of,  47. 

-  -  Outside   and    Inside   of    Frog's 

Ventricle,  269  et  sqq. 

—  Splanchnic  Area,  335. 
.  -  as  Hypnotic,  488. 

-  Liquor,  with  Salicylate  of  Soda  in 

Cardiac    Failure    of    Acute 
Rheumatism,  375. 

-  as  Vaso-constrictor,  835. 
Strychnine  and  Arsenic  Solution,  in 

Raynaud's  Disease,  450. 

-  and  Digitalis  in  Aortic  Regurgita- 

tion, 406. 

-  Sulphate   of,    with    Salicylate    of 

Sodium  in  Cardiac  Failure  of 
Acute  Rheumatism,  375. 

-  Uses  of,  in 

-  -  Brady cardia,  after  Fever,  421. 

-  -  Cardiac  Asthma,  445. 

-  -  Cardiac  Failure  of  Acute  Rheu- 

matism, 375. 

-  -  Cerebral  Thrombosis,  456. 

—  Endocarditis,  377. 

-  -  Intervals  of  Paroxysmal  Tachy- 

cardia, 418. 

-  -  Irregular  or  Feeble  Pulse,  817. 
Subacetate   of   Lead    Ointment   for 

Pruritus  ani,  480. 

Subclavian  Artery,  Throbbing  of,  177. 

Subcutaneous     Injections     of    Mor- 
phine in 

Angina  Pectoris  Attacks,  442. 


Subcutaneous  Injections  of  Mor- 
phine in  (cont.) 

Cardiac  Insomnia  (distressing), 

486,  437. 

Submaxillary  Gland,  Dilatation  in, 
how  Induced,  87. 

-  -  Effect  on,  of  Irritation  of  Chorda 

Tympani,  parallel  to,  181, 897. 

Substituted  Urea  Group  of  Hypnotics, 
435-6. 

Suction- action  of  Heart,  how  In- 
duced, 9,  154,  (fig.)  155 ;  In- 
crease of,  by  Digitalis,  809. 

Sugar,  Internal  Secretion  of,  by  the 
Liver,  89. 

-  Treatment  of  Fail  ing  Heart.253,287. 
Sugars,  at  Cardiac  Nutrients,  287. 
Sulphate  of  Sodium,  as  Diuretic,  350. 

-  of  Strychnine,  in  Cardiac  Failure 

of  Acute  Rheumatism,  375. 

-  of  Zinc  as  Emetic  in  Paroxysmal 

Tachycardia,  418. 
Snlpho-carbolate  of  Soda,  as  Gastric 

Antiseptic,  856. 
Sulphonal   as    Hypnotic,   how  Best 

Given,  435. 
Sulphur-alkyl  Group  of  Hypnotics, 

485. 
Sumbul   for    Flushes    of  Heat   and 

Blushing,  449. 
Superficial      Cardiac      Plexus,     63; 

Branches  of  Left  Vagus  going 

to,  67. 

-  Veins,  in  Hind  Legs  of  Animals, 

Effect  on,  of  Irritation  of  the 

Sciatic  Nerve,  87. 
Suppository  for  Pruritus  ani,  429. 
Suppuration,  What  it  Indicates,  451-2. 
Suprarenal   Extract,  see   Adrenalin, 

Adrenin,  £e. 

-  Glands,      Diseases      of,      Effects 

of,    According    to    Portion 
Affected,  289-90. 

-  Effects  of,  on  Blood-pressure,  90. 

-  -  on  Maintenance  of  Heart's  Tone, 

289. 

-  Effects  on,  of  Diphtheria,  160. 

-  Vein,  Amount  of  Adrenalin  in,  289. 
Surgery,  Shock  in,  179. 
Swallowing   Air,    Flatulence    from ; 

Causes ;  Treatment,  856. 
Switzerland,  Graduated  Walks  in,250. 
Sylvian  Artery,  Embolism,  &c.,  of, 

Aphasia  due  to,  205. 
Sympathetic   Ganglia,   Nicotine    as 

Affecting,  275. 

-  Nerve(s),  Action  on,  of  Adrenalin, 

Parts  Affected  by,  815. 

2  M 


522 


INDEX 


Sympathetic  Nerve{s)(con<.) 

—  Association  with,  of  Vaso-motor 

System,  86. 

—  Fibres  of,  Contained    In    Vagus 

Trunks,  Possible  Conse- 
quences of  Stimulation  of  the 
latter,  67. 

-  -  Function  of,  64. 

-  System,     Hyper-excitability     of, 

towards  Adrenalin,  Produced 
by    Withdrawal   of   Normal 
Calcium  Salts,  279. 
Symptoms,  Treatment  of,  411  et  «</'/. 

-  -  Bibliography  of,  457  et  sqq. 

-  of    Disordered     Circulation,    176 

et  sqq. 
Syncope,  Blood-pressure  Low  in,  181. 

-  Causes,  17, 180. 

-  Fatal,  in  Aortic  Disease,  404,  405, 

407,  (fig.)  405. 

-  -  from  Excessive  Pain,  178-9. 

-  -  from  Excessive  Use  of  Digitalis, 

318. 

-  Flow  of  Blood  during,   Hunter's 

Observation  on,  180-1. 

-  Risk  of,  in  Tapping  for  Ascites, 

How  Met,  201. 

-  and  Shock,  Difference  between,  180. 
Synthetic  Adrenalin,  815. 

-  Compounds  of  Sodium  and  Theo- 

bromine,  Diuretic  Uses  of, 
818-9. 

Syntonin,  Non-Nutrient  to  the  Heart, 
286. 

Syphilis,  Heart-block  from,  Treat- 
ment, 487. 

Syphilitic  Endarteritis,  Cerebral 
Thrombosis  from,  Treat- 
ment, 457. 

Systole,  Auricular,  187,  and  Ven- 
tricular, Changes  in  Length 
of,  from  Compression  of 
Bundle  of  His,  69-60. 

-  Extra,  Causes,  46,  58-4,  64-5, 171-3. 

-  in  Frog's  Heart,  Electrical  Stimula- 

tion of  Ventricle  during, 
Effects  at  Different  Stages, 
44-6. 

-  Heart's   Work   at,   Lightened    by. 

Massage  and  Beat,  238. 

-  Prolongation    of,    Effects    of,    on 

Second  Sound,  211. 

-  Standstill  in,  of  Frog's  Heart,  from 

Digitalis,  308. 

-  -  Caused  by  Perfusion  with  Saline 

and  Calcium  alone,  285. 

-  Ventricular,  74, 125, 129, 187,  (figs.) 

76, 124. 


Systolic  Blood-pressure,  Age,  Sex, 
and  Race  Variations  in, 
109-10. 

-  -  on  What  Dependent,  118. 

-  -  in  Relation  to  Diastolic,  115  rt 

sy</.,  and  Difference  from,  in 
Aortic  Regurgitation,  404-5. 

-  Contraction,  Effect  on,  of  Digitalis, 

299. 

TABES  Dorsalis,  Angina  Abdominis 
in,  195-6. 

-  Antipyrin  in,  Action  of,  444. 
Tachycardia,  Action  in,  of  Alkalies, 

357. 
—  Diagnostic  Indications  from,  163. 

-  -  from  Strain,  Treatment,  417,  (fig.) 

418. 

-  -  in  Graves's  Disease,  Treatment, 

415. 

-  -  Induced  by  Coffee  and  Tea,  168. 

-  Experimental,   from    Ligature   of 

Coronary  Artery  (Lews),  165. 

-  Paroxysmal,  Causes,  .Nature  and 

Treatment,  417  et  t'l'i.,  (fig.) 
418. 

Tambour,  and  Apparatus  for  Record- 
ing Venous  Pulsation,  186. 

-  Form    of   Cardiograph    for  Apex 

Beat,  126,  127,  and  for  Re- 
spiration, 127. 

Tanghenia  venenifera,  811. 

Tannic  Acid  and  Tincture  of  Iodine, 
on  Tonsils,  883 

Tap- water,  Saline  Solution  made  with, 
Ringer's  Discovery  on,  285. 

Tapping  for 

-  Ascites,  261-2,  (Jigs.)  262,  851-2. 

-  (Edema,  260. 

Tartar  Emetic,  Action  of,  804. 

-  with  Opium,  as  Soporific,  364. 
Tartrate  of  Potassium,  as  Diuretic, 

850. 
Taste  of  Drugs,  Masking  Methods, 

840-1,  413. 
Tea,  Action  of,  on  Nerves  and  Heart, 

and   Centra-indications   for, 

168,  318,  886,  411,  415,  420, 

425,  443. 

Tears,  Increase  of,  by  Adrenalin,  815. 
Teeth,Aching,Mouth-wash  to  relieve, 

426. 

-  Artificial,  When  Necessary,  382. 

-  Decay  or  Lack  of,  &c.,  Cause  of 

Dyspepsia,  882-3. 

-  Extraction  of,  When  Needful,  447. 

-  Irritation    in,    Causes ;    Results ; 

Treatment,  446-7. 


INDEX 


523 


Teeth  (con«.) 

-  Pain    from   Roots,  Why  Relieved 

by  Cold,  254. 

Temperature,  Bodily,  see  also  Febrile, 
Fevers,  (fc. 

-  -  Effect  of,  on   Drug-action,  273, 

281-2. 

-  in  Endocarditis,  367-8,  How  Best 

Regulated,  376. 

-  Equilibrium  of,  93-4. 

-  High,  Insomnia  from,  364. 

-  Taking  of,  in  Rheumatic  Fever, 

&c.,  when    Heart    may    be 
Affected,  367-8. 

Temperature,  Climatic  and  Seasonal, 
see  also  Heat  and  Cold. 

-  Effect   of,   on    Drug-action,    281, 

283. 

-  -  on  Pulse-rate,  162-8. 
Temporal  Arteries,  as   affected    by 

Aortic   Regurgitation,    404 ; 

in  Migraine,  183-4,  (Jig.)  184. 
Tensor     vagime     femoris     Muscle, 

Function,  12. 
Terebinthinse,   Oil    of,   Carminative 

Uses  of,  360. 
Terebinthine  Preparations  used  with 

Bottle  for  giving  Medicated 

Oxygen,  in  Bronchitis,  242-3. 
Tetanus,    not    caused    by*  Electric 

Stimuli  to  Heart,  55-ti. 
Tetronal,  as  Hypnotic,  435. 
Tliebaine,  Action  of,  278. 
Thebesius,  Vessels  of,   Maintenance 

by,     of     Circulation     after 

Coronary  Obstruction,  153. 
Theobromine,  as  Dilator  of  Coronary 

Arteries,  344. 

-  as  Diuretic,  318,  348,  Action  of, 

on  Kidney  Circulation,  849. 

-  as  Nervous  Stimulant,  317-9. 

-  and  Sodium,  Synthetic  Compound 

of,  Diuretic  Uses  of,  318-9. 
Theocine,  Nature  and  Uses  of,  819. 

-  as   Diuretic,    848,    Action    of,  on 

Kidney  Circulation,  849. 

Theophyllin,  Nature,  Uses  and 
Synthetic  form  of,  319 ;  as 
Diuretic,  848,  Action  of,  on 
Kidneys,  849. 

Therapeutical  Application  of  Digi- 
talis, due  to  Traube,  295-6. 

Thermometer,  Use  of,  in  Detecting 
Cardiac  Mischief,  in  Rheu- 
matic Fever,  &c.,  367-8. 

Thermos  Flask,  &c.,  for  Night  Food, 
in  Insomnia,  481. 

Thevetia  grandiflora,  811. 


Thickening   of   Mucous   Membrane, 
Action  of,  on  Pylorus,  389-90, 


Third  Nerve,  Action  on,  of  Atropine, 

274. 
Third  Sound  of  the  Heart,  see  undtr 

Sounds. 
Thirst,    from    Diuretic    Action    of 

Digitalis,  308,  310. 
Thorax,    Effect   on,    of  Ventricular 

Contraction,  9. 

-  Pain  in,  Poultices  for,  255-7. 
Throat,  Irritability  from   Excessive 

Smoking,  327. 
Throbbing  (see  also  Pulsation),  of 

Arteries,  177. 
Thrombosis,  of  Arteries,  Causes  and 

Results,    186,    204-6,    (figs.) 

205.  206. 

-  Cerebral,  Treatment,  456-7. 

-  Differential  Diagnosis  of,  from 

-  -  Cerebral  Haemorrhage,  Wright's 

Method.  145-6. 

-  -  Embolism,  Difficulty  of,  205. 
Thyroid  Extract,  Adrenalin  Antagon- 

istic in  action  to,  416. 

-  -  Effect  on  Blood-pressure,  89-90. 

-  -  for  Chilblains,  450. 

-  -  Overlong  Administration  of,  Pal- 

pitation from.  165,  415. 

-  -  in  Raynaud's  Disease,  450. 

-  Gland    Secretion,    Action    of,    on 

Body,  396-7. 

-  -  Effect  on  Blood-pressure,  89-90. 
Tight-lacing,    Cardiac  Displacement 

from,  227-8. 
Tinctures,  see  Names  of  Drugs,  £c., 

used  in  Tincture  Forms. 
Tiodine,  in  Angina  Pectoris,  444. 
Tiredness,  Excessive,  and  Simple,  in 

relation  to  Sleep,  438. 
Tissue-Change,  Drugs  affecting,  In- 

direct Action   of,  on  Heart 

and  Vessels,  284. 

-  -  in  Heart,  Influence  on,  of  Vagus, 

71. 

Tissue-juice,  see  Lymph. 

Tissue-Metabolism,  as  affecting  Con- 
dition of  Blood  ;  on  What 
itself  Dependent,  381  ;  Waste 
Products  of  (see  also  Elimina- 
tion), 13. 

Tissues  Circulation  in,  benefited  by 
Digitalis,  308. 

-  Inflamed,  Yielding  and  Unyielding, 

Applications  to,  of  Heat  and 
Cold,  254. 

-  Nourishment  of,  9,  77. 


524 


INDEX 


Tissues  (cant.) 

-  Selective    Action    on,    of    Drugs, 

278,  274. 
Toad's  skin,  Poison  from,  Similar  in 

Action   to    Digitalis,    Story 

on,  311-2. 
Tobacco,  Action  of,  324. 

-  -  Chewed,  825. 

-  -  Smoked,  181, 182,  325-8. 
--Snuffed,  825. 

-  Contra-indications  for,  415,  420. 

-  Enemata,  former  Uses  of,  324. 

-  Poisoning. 

-  -  Bigeminal  Pulse  from,  170. 

-  -  Bradycardia  from,  108. 

-  Smoking,  325-8. 

-  -  Attractions  of,  826-7. 

-  -  Excessive,    Results,    Low    Ten- 

sion, 181,  182,  193,  827-8,451. 

Palpitation,  411. 

Tolerance.  Variable,  of  CO2, 18-4. 
Tone  of  Heart,  Glands  maintaining, 

289. 

-  Lack  of,  in  Blood-vessels,  Effect 

of,  and  Treatment,  432. 

-  Normal,  of  Bladder,  288-9. 

-  -  of  Involuntary  Muscles,  288-9. 
Tongue,  Effect  on,  of  Aconite,  828. 

-  Irritation     of,     from     Excessive 

Smoking,  827. 

Tonic  Action  of  Vagi,  how  Altered, 
and  Maintained,  161. 

-  Contraction,  induced   by  Caffeine 

and  by  Digitalis,  in  relation 

to  Oxidation,  298. 
Tonicity  of  Ventricle,  56,  68. 
Tonics,    Cardiac,    Action    of,    284, 

288  et  sqq. 
-  Bibliography  on,  319-22. 

-  for  Bradycardia  of  Fever  Conval- 

escence, 421. 

-  for  Digestion,  in  Low  Tension,  451. 
Tonometer,  Gaertner's,  103,  (fig.)  104. 
Tonsillitis,  Aconite  in,  329. 

-  Cold  Wet  Compress  in,  254-5. 

-  Removal  of  Tonsils  for,  878,  883. 
Tonsils,  Removal  of,  when  indicated, 

378,  888. 
Tortoises,  Inhibitory  Power  of  Right 

Vagus  in,  67. 
Toxaemia,  Headache  from,  446. 

-  Heat  ft  ashes  of  Menopause  and,  177. 
Toxamines,  Production  and  Nature, 

894,    Action   on,  of   Purga- 
tives, 358. 

Toxic  Action  of  Drugs,  &c.,  see  oZso 
Poisoning,  and  under  Names 
of  Drugs,  <Cc. 


Toxins  (ste  also  Poisons),  Act  ion  of,  on 
MuscularFibres  of  Heart, 152. 

-  Analogous   in    Action    to   Supra- 

renal Extract,  90,  91  <ln. 

-  in  Bile,  Mercurials  to  Eliminate, 

854,  Saline,  as  adjunct  to,  855. 

-  Contraction  of  Arterioles  due  to, 

High  Tension  caused  by,  200. 

-  of  Disease,  Bradycardia  from,  163, 

167-8. 

Effects  of  Temperature  on,  Pulse- 
rate  Modified  by,  168. 

-  Expulsion  of,  means  of,  447. 

-  Formation  in  Stomach,  &c.,  How 

Lessened,  420. 

-  Nature  and  Derivation  of,  Gastric 

Disinfectants  for,  855. 

Trabeculse,  Fatty  Degeneration 
Patches  affecting,  161. 

Transient  Cardiac  Murmurs,  Causes 
and  Indications,  217-8. 

Transmission  of  Stimuli,  through 
A-V  Bundle,  286. 

Transudation  from  Blood-vessels  into 
Tissues  (see  also  Serous  Effu- 
sion), 252. 

-Chloride-free  Diet  to  Diminish, 
252-8. 

Transverse  Contraction,  hypotheti- 
cal,  of  Muscle,  86,  (fig.)  ib. 

Traube's  Experiments  on  Digitalis- 
action,  Importance  of,  295-6. 

Treatment  of 

-  Acute  Heart  Disease,  3(56  et  sqq. 

Bibliography,  879  et  sqq. 

-Cardiac  Disease,  Method   of,  282 

et  sqq. 

-  -  Bibliography,  264-5. 
Hopefulness  of,  282. 

-  Chronic   Heart    Disease,    General 

Principles  of,  880  et  sqq. 

Bibliography,  898  ft  sqq. 

Valvular,  402  et  sqq. 

Bibliography,  410. 

-  Symptoms,    and    Functional   Dis- 

eases, 411  et  sqq. 

Bibliography,  457  et  sqq. 

Tremor,  Nervous,  from  Excessive 
Smoking,  827. 

Trephining  for  Cerebral  Abscess, 
Effect  on  Pulse-rate,  162. 

Tricuspid  Valves,  Action  of,  Bene- 
fited by  Digitalis,  809. 

-  Failure  or  Incompetence  of,  Re- 

sults, 19,  223. 

-  -  Tendency  to,  as  Safeguard,  78. 

-  Regurgitation  in,  78,  215,  (fig.)  75; 

Venous  Pulse  in,  135. 


INDEX 


525 


Trimetnylxanthine,  or  Caffeine  (q.v.), 

288. 

Trional,  as  Hypnotic,  435. 
Trisodium  Phosphate,to  render  Theo- 

bromine  more  Soluble,  318. 
Trophic  Action  of  Vagus,  70-1. 
Tube,     Rectal,     for    Expulsion    of 

Flatulence,  362. 
Tuberculosis   associated    with    Low 

Tension,  181,  451. 

-  iu  the  Young,  Predisposition  aris- 

ing from  Grief,  160. 

Tumour,  see  Cerebral  Tumour. 

Turpentine  Stupe,  to  stimulate 
feeble  Cardiac  Action,  263. 

Turtle,  Loggerhead,  Heart  of,  Inhi- 
bition in,  39. 

Typhoid  Fever,  Blood-pressure  Low 
in,  181. 

-  Bradycardia  in,  163,  167. 

-  Fatty  Degeneration  in,  160,  <t  see 

152. 

-  Haemorrhage     in,      Pituitriu     to 

lessen,  319. 

-  Inaudibility   in,   of   First    Heart 

Sound,  Prognosis,  212. 

-  Pulse-rate  in,  163,  167. 

-  Why  not  often  Followed  by  Cardiac 

Symptoms,  869. 
Tyrosin,  Source  of,  91. 

ULCBRATIVB  Endocarditis,Fatal  from 
Pyorrhoja  alveolaris,  388. 

Ulcers  (see  under  Names),  Linseed 
Poultices  for,  how  Applied, 
255. 

Universal  (Edema,  due  to  Anti-strep- 
tococci Serum,  199. 

Upas  (Antiaris  toxicaria),  811. 

Uphill  Walking,  in  Oercel's  Treat- 
ment, Reason  for,  250,  251. 

Upright  Position,  Greater  Ease  of 
Breathing  in,  Why,  234. 

Upstairs,  Walking,  Exertion  of,  232-3. 

Urates,  Action  on,  of  Liver,  395. 

Uraemia,  Poison  of,  Bradycardia 
Caused  by,  188. 

Urea,  as  Diuretic,  348 ;  Action  of,  on 
Kidney  Circulation,  849. 

-  Excretion  of,  in  Urine,  Diet  and 

Climate  as  Affecting,  847. 

-  Urates  Converted  into,  by  Liver, 

395. 

Ureas,  Substituted,  Group  of,  as 
Hypnotics,  435-6. 

Ureter,  Effect  on,  of  External  Pres- 
sure, and  Internal  Disten- 
sion, 186. 


Ureteral  Obstructions;  Causes;  Re- 
sults; Treatment,  352,  (Jig.) 
t&. 

Urethane,  as  Hypnotic,  435. 

Urginea  Scilla  (Squill),  311. 

Urinal  for  Rheumatic  Fever  Patients, 
870. 

Urinary  Bladder,  Effect  on,  of  Ex- 
ternal Pressure,  and  Internal 
Distension,  186. 

--Inhibition  of,  by  Adrenalin, 
315. 

-  -  Pain  in,  from  Resistance  to  Effort 

to  Empty  itself,  Angina  Pain 
Analogous  to,  189-90. 

-  -  Tone  of,  Normal  and  Disturbed, 

288-9. 
Urinary  Secretion,  see  Urine. 

-  System,    Action    on,    of    Drugs, 

346  et  sqq. ;  Bibliography, 
865. 

Urine,  Albumen  in,  in  Mitral  Disease, 
not  a  Coutra-indication  for 
Opium,  865. 

-  Alkalinity  of,  at  Height  of  Gastric 

Digestion,  391 ;  in  Pyloric 
Stenosis,  892;  Increased  by 
Blistering,  376. 

-  Excretion  and  Flow  of,  Diet  and 

Climate  as  Affecting,  347. 

-  Rising   Suddenly   to    Pass,    Risk 

from,  in  Aortic  Regurgita. 
tion,  406. 

-  Secretion  and  Flow  of,  Action  on,  of 
Caffeine    and     other     Purins, 

318-9. 

Digitalis 

Medicinal,  305-7,   809,   Risks 

with,  813. 

Toxic,  303,  804. 

Erythrophloeum,  303,  304,  805, 

307,  (fig.)S06. 

Massage  and  Rest,  289. 

Pituitrin,  819. 

Venous  Engorgement,  224,  225, 

—  Cessation  of,  in  Man,  Prognosis, 

803,  304. 

-  -  Ludwig's  Theory  of,  346. 

-  Urates  in,  from  Imperfect  Liver 

Action,  395. 
Uropherin,    Nature    and    Uses    of, 

318-9. 
Urticaria,  Causes  and  Nature,  198; 

Treatment,  450. 

-  Chronic,  Treatment,  450-1. 

Uterus,  Contraction  of,  by  Adrena- 
lin, 815 ;  by  Pituitary  Ex- 
tract, 819. 


526 


INDEX 


VACCINE  Treatment  of 

-  -  Pyorrhoea  alveolaris,  888. 

-  -  Septic    Endocarditis    and    Peri- 

carditis (autogenous),  878. 

-  -  Urticaria,  451. 
Vagus  Nerves  or  Vagi. 

-  Accelerating  Fibres  in,  71. 

-  Action  of,  Mode  of,  Possibly  Chemi- 

cal, 286;  Problems  of,  66-7. 

—  on    Heart,    Normal,    Influenced 

by  Digitalis,  and  by  Stimula- 
tion, 66,  61 ,  65,  et  sqq. ,  69  et 
sqq.,  281,  286,  295,  301.  305, 
(/?£«.)  69,  145,  800,  302. 

-  Action  on,  of 

-  -  Atropine,  in  Small  Doses,  274. 

-  -  Digitalis,  in  Slowing  the  Heart, 

281 ;  Traube's  Discovery,  295; 
Parts  Affected  by,  808. 

-  -  Emotions,  158-9. 

-  Centre  of,  in  Medulla. 

—  Action  on,  of 

Aconite,  328. 

Digitalis,  61,  807. 

Excessive    Tension    in    Blood- 
vessels, 17-8. 

-  -  InhibitoryCentrefortheHeart,67. 

-  End  in  Heart,  Action  on,  of 

-  -  Aconite,  828. 

-  -  Nicotine,  277. 

-  in  Frog's  Heart. 

-  -  Ganglion  of,  26. 

-  -  Inhibiting  Action  of,  39. 

-  Functions  of,  Complexity  of,  64 ;   j 

Gaskell  on,  70-1. 

-  Gastric  Branches  of,  Reflex  Cardiac 

Irritation  from,  Relieved  by 
Alkalies,  357,  (fig.)  358. 

-  Inhibitory  Centre  and  Fibres  of 

—  Action  on,  of 
Adrenalin,  276. 

Cardiac  Perfusion,  71. 

-  -  Digitalis,  298. 

-  -  Function  of,  64,  How  Exercised, 

67  et  sqq. 

-  -  Origin,  67. 

-  Irritation  of,  Effect  on  Heart,  801. 

-  -  Electro-cardiogram  during  (Jig.), 

145. 

-  -  Removal    of,    in    Bradycardia, 

Methods,  420. 

-  Left,  Branches  of,  Joining  Super- 

ficial Cardiac  Plexus,  67. 

-  Nerves   from,    to    Various    other 

Parts  and  Nerves,  64. 

-  Neuritis   of,    Probable   Cause    of 

Bradycardia  in  Convalescence 
from  Diphtheria,  167  8. 


Vagu8(can«.) 

-  Opposite  Action  of,  67-9. 

-  Origin,  Position,  and  Function,  67. 

-  Paralysis  of, Variously  Caused,71-2, 

152,  Effect  of,  on  Pulse-rate, 
&c. ,  160,  163  et  tqq. 

-  -  by  Atropine,  274,  421. 

-  -  by  Curare,  276. 

-  Part  Played  by,  in  Producing  Sense 

of  Oppression  on  Chest,  186, 
in  Grief,  Author's  Experience 
of,  187,  Czermak's  Experi- 
ment with,  187<£n. 

-  Right,  Branches  of,  Joining  Deep 

Cardiac  Plexus,  67. 
-  -  Inhibitory  Power  of,  67. 

-  Right  and  Left,  Special  Power  of, 

68,  (fig.)  69. 

-  Roots,  Effect  of,  on  Co-ordination 

of  Heart's  Action  and  Blood- 
pressure,  17-8. 

—  Effect  on,  of 

Anaemia,  18. 

Digitalis,  303. 

-  -  Stimulation   of.  Various    Modes 

of,  420. 

Reflex,  Action  of,  on  Pulse,  172, 

438. 

-  Section   of,  Effects   in    and    after 

Life,  70,  71. 

-  -  in    Fowls   and    Rabbits,    Fatty 

Degeneration  from,  160. 

-  -  under  Nicotine.  Results,  824. 

-  Stimulation  of,  Effects,  see  Action 

on  Heart. 

-  -  in  Relief  of  Paroxysmal  Tachy- 

cardia, Two  Methods  of,  419. 

-  Three  Kinds  of  Nerves  Contained 

by,  64. 

-  Trophic  Action  of,  70-1. 

-  Trunk,  Depressor  Nerves  Associ- 

ated  with,  21,  65. 

-  -  Effect  of  Irritating,  267. 

-  -  Stimulation      of,     by     Faradic 

Current,  Effect  on  Cardiac 
Pulsations,  61. 

-  -  -  Effect  on  Sympathetic  Fibres 

in,  67. 

Valerian  for    Flushes    of  Heat   and 
Blushing,  449. 

-  in  Graves's  Disease,  416. 

-  in  Palpitation,  414. 
Valerianate  of  Zinc,  for  Flushes  of 

Heat  and  Blushing,  449. 
Valsalva's     Experiment    in     Heart 

Stoppage,  172,  228. 
Valves  of  the  Heart,  see  alto  wndrr 

Names. 


INDEX 


527 


Valves  (coni.) 

—  Action  of,  78  et  sqq.,  Apparatus   I 

for  Demonstrating  (fig.),  74. 

—  Contraction  of,   in    relation    to   , 

Cardiac  Murmurs,  Organic, 
214-5. 

—  Dilatation    of,    in    relation    to 

Cardiac     Murmurs,     Func- 
tional, 214-5,  (fig.)  75. 

-  -  Functions  of,  78-5,  (figs.),  74,  75. 

-  -  How  kept  in  Place,  74,  (fig.)  ib. 

-  -  Power  of,  in  Systole,  Lack  of,  in 

Distention(/J$r.),  75. 
Valvular  Disease,  from  After-effects 
of  Acute  Cardiac  Diseases, 
Deaths  from,  more  frequent 
than  from  the  Diseases  them- 
selves, 867. 

—  Chronic,  Brown  Atrophy  in,  153 ; 

Treatment,  402  et  sqq. 
-  -  Pleural  Effusion  in,  Serious  Com- 
plication of,  289. 

-  Incompetence  (fig.),  75. 

-  -  Cardiac  Murmurs  from,  218  et  sqq. 

—  from  Dilatation  only,  Curable  by 

Digitalis,  809. 

—  Secondary  (Functional),  Results 

of,  219,  228. 

Varicosities  on  Nerves,  Nature  of,  68. 
Vasa  Vasorum  of  Artery,  Effect  on,  of 

Pulsations  of  theHeart,10-ll. 

-  Functions    of,    and     Importance, 

156-7. 
-Local  Infiltration  about ;  Causes ; 

Results,  199. 

Vascular  Areas,  Four  Largest,  19. 
Vascular  and  Cardiac  Remedies. 

Action  of,  266  et  sqq. 

Bibliography  of,  290  et  sqq. 

Classification  of,  284. 

-  Congestion,  and   Contraction,    as 

Cause  of  Headaches  and  of 
Migraine,  446. 

-  Contractors,  284. 

-  Dilators,  284. 

-  Excitant,  Camphor  as,  316. 

-  Spasm,  in 

-  -  Angina  Pectoris,  191. 

—  Migraine,  185. 

-  System,  Hydrostatic  Pressure  in, 

E  fleets  of,  on  Venal  Circula- 
tion, 9. 

Vaso-constrictors,  see  Camphor,  Digi- 
talis, .ic. 

Vaso-dilators,  284,  813,  835,  338,  389, 

340,  844. 

-in    Aortic     Regurgitation,     with 
Digitalis,  Value  of,  406. 


Vaso-dilators  (cont.) 

-  in  Aortic  Stenosis,  403. 

-  Classes  of,  839. 

-  in  High  Tension,  413. 

-  History  of  their  Discovery,  385. 

-  Iodides  as,  Mode  of  Action,  840. 

-  Nitrites,  Nitrates,  and  the  Nitrous 

group,  335-9. 

-  in  Paroxysmal  Tachycardia,  When 

Needed,  418-9. 
Vaso-motor 

-  Contractors,  819,  338-5. 

-  -  Central,  335. 

-  -  Peripheral,  333-5. 

-  Nerves,  Action   on,  of   Digitalis, 

Discovered  by  Traube,  295; 

as  affecting  (Edema,  310-11. 
—  Action  on,  of 

Caffeine,  276,  318. 

Camphor,  316. 

Digitalis,  298,  308,  318. 

Nicotine,  823-4. 

-  -  Centres  of,  Chief,  in  Medulla,  and 

others,  85. 
Function  of,  in  Regulation  of 

Distribution  of  Blood,  17-8, 

305-6,  332. 
Influence  of,  on  the  Splanchnic 

Area,  19. 

-  -  Megrim  due  to  Altered  Action  of, 

185. 

-  -  Weakness  of,  CEdema  due  to,  224, 

Ranvier's    Experiment    on, 
810-11. 

Vaso-motor  Power,  Deficient,  as  a 
Cause  of  Sleeplessness,  364. 

-  System,    Stimulation   of,    Reflex, 

in  Relief  of  Faintness,  422-8. 

Vegetable  Charcoal  as  Gastric  Anti- 
septic, 856. 

Vegetables  in  Diet  of  Convalescents 
from  Acute  Heart  Disease, 
379. 

Vegetarian  Diet,  in  Angina  Pectoris, 
443. 

Vegetation  on  Cardiac  Valves,  Effects 
of,  215,  220. 

Veins,  see  Dog,  see  also  under  Names. 

-  and  Arteries,  Common  Sheath  of, 

uses  of,  10,  156,  (figs.)  ib. 

-  Best    Suited    for    Letting   Blood 

from,  259. 

-  Blood-pressure    in,    Increased    in 

Mitral  Disease,  351. 

-  Circulation  to,  in,  and  through,  9. 

-  Contraction  of,  87-8 ;  Rhythmical, 

Source  of,  22. 

-  Dilatation  of,  88. 


528 


INDEX 


Veins  (cont.) 

-  Independent  Pulsation  of,  21-2. 

-  Stretched,   Greater  Capacity  and 

Suction  Action  of,  11. 

-  Valves  in,  Functions,  10. 

Venae  Cavse,  Contractile  Power  of, 
222. 

-  Independent  Pulsation  of,  21-2,  65, 

77-8,  (fig».)  41,  Causes,  222. 

-  Inferior,    Impulse    Received     by 

Blood  in,  9. 

-  Stimulus    at,    Extra   Systole   In- 

duced  by,  no  Compensatory 
Pause  after,  46. 

-  Tension  in,  as  Affected  by  Raising 

the  Legs,  234. 

-  Valvelessness  of,  and  Venous  En- 

gorgement, 223. 
Venesection,  see  Blood-letting. 
Venous  Blood-pressure,  Measurement 

of,  119-20. 

-  Capillaries,  Yielding  of,  Cause  and 

Results,  223-4. 

-  Circulation,  154. 

-  -  Action  on,  of  the  Fasciie  of  the 

Limbs,  11-12,  154. 

-  -  Benefited  by  Digitalis,  809. 

-  Course  and  Maintenance  of,  9  et  «'/'/• , 

(fly.)  10. 

-  Congestion,    Abdominal,  Results, 

224,  226. 

-  -  Benefited  by  Digitalis,  309,  811. 

-  Engorgement,  Causes  and  Results, 

223-4,  228,  423. 

-  -  Tendency   to,    Nauheim    Treat- 

ment for,  243  et  s<y/. 

-  Obstruction,     without     (Kdeina, 

Ranvier's    Experiment    De- 
monstrating, 310-11. 

-  Pulse,  185. 

-  -  Characters  of,  136-7,  (fig.)  137. 

-  -  Sphygmograms  of,  136,  (ftg.)  137. 

-  Sinus,    Ligature   of   Heart   near, 

Effect  of,  40  et  «</</. ,  (  figs.)  41. 

-  -  in  Frog's  Heart,  20,  42. 

Contraction  of,  as  Motor  of 

Circulation,  25,  31. 

Electrical  and  other  Stimula- 
tion of,  Effects  of,  Author's 
and  others'  Investigations, 
44-6,  (figi.)  45. 

Inhibitory,  Apparatus,  prob- 
able on,  42. 

Pulsatile  Contraction  of,  21. 

-  -  Stimulation  of,  Effect  on  Heart, 

824. 

Venom  Stasis,  in  Aortic  Incompe- 
tence, 403. 


Ventricle^),   tee  also   Auricle,   ami 
Frog. 

-  Action  on,  of  Accelerators,  72,  of 

Vagus,  68,  (fig.)  69,  and  of 
Vagus  Stimulation,  66. 

-  Compensatory  Hypertrophy  of,  in 

Aortic  Stenosis,  402. 

-  and  Auricles,  Conducting    Paths 

between,  28,  31,  69. 

-  -  Effect    on,    of    Stimulation    of 

Vagus,  38,  68,  145,  (ftgt.)  69, 
145. 

-  Contraction  of  (Systole),  65. 

-  Diminution  of  Size  in,  Causes,  221. 
-Fibrillation  of;  Causes;  Results; 

Treatment,  61-8. 

-  Left,  in  Relation  to  Bradycardia, 

165,  (/Zff.)166. 

-  Mammalian  Heart,  Motor  Action 

of,  25-6. 

-  -  Muscular  Fibres  of,  50-2. 

-  Non-simultaneous    Action   of,    as 

Affecting  Heart  Sounds,  211, 
212. 

-  Right,  Detention  of,  Valvular  In- 

competence from,  78. 

-  -  Hypertrophy  of,  Causes,  223. 

-  -  Part    Played    by,    in     Causing 

Breathleasness,  182. 

-  -  Strength   of,  and  Tendency    to 

Valvular  Incompetence,  78. 

-  -  Weakness     of,    Symptoms     of, 

Similar  to  those  of  Venous 
Engorgement,  228. 

-  Right  and  Left,  Areas  supplied  by, 

Result  of  Interference  with, 
196. 

-  Safety-valve  Action  of,  78. 

-  Septum,  Nerve  Fibres  in,  62 ;  Punc- 

ture of,  Effects  of,  61-8. 

-  Standstill  of,  how  Induced,  78. 

-  Stimulation  of,  Fibrillation  from, 

63. 

-  Stimuli  to,  Conduction  of.  When 

probably  Aflected,  161. 

-  Yield  of,  in  Aortic  Rcgurgitation, 

403,  406  ;  Treatment,  407.    - 
Ventricular  Activity,  Factors  of,  56. 

-  Asynchronism.as  Affecting  Cardiac 

Soundi,  210. 

-  Beat,  Nature  of,  55. 

-  -  Effect  on,  of  Caffeine  in  Small 

Doses,  288. 

-  -  in  Frog's  Heart,  as  Affected  by 

Stimulation  of  Venous  Sinus, 
45,  (fig-)  U. 

-  -  Senile  Pulse  in  Relation  to  (fig-), 

126. 


529 


Ventricular  Contraction  or  Systole,  55. 

-  -  Action  of,  on  the  Circulation,  9, 

154. 
—  Action  on,  of  Atropine,  and  of 

Hyoscyamine,  Differing  with 

Temperature,  282. 
of  Digitalis,  299. 

-  -  Arterial  Distention  during,  Effect 

of,  10. 

-  -  Changes  of  Pressure  during,  125, 

129 ;  Tracing  of,  after  Marey 
(fig.),  124. 

-  -  Coincidence    with,    of    Carotid 

Pulse,  187. 

-  -  Ectopic,  and  Nomotopic,  58. 

-  -  Extra,  Causes,  171-3. 

-  -  Heart  Sound  due  to,  76,  77. 

-  -  Rapidity  of,  Causes,  and  Effects 

on  First  Heart  Sound,  212-3. 

-  -  Suction  Action  exerted  during, 

as  Affecting  Circulation,  9, 
154,  (fig.)  155,  Increased  by 
Digitalis,  309. 

-  Dilatation,  Causes,  218-9. 

-  B^-ra  Sound,  Causing  Reduplica- 

tion of  First  Heart  Sound, 
212. 

-  Fibrillation,  in  Ligature,  &c.,  of 

Coronary  Artery,  168. 

-  Hypertrophy,  Causes  of,  218,  219, 

223. 

Veratrine,  Action  of,  on  Frog's 
Muscle,  differing  with  Tem- 
peratures, 282,  (  fig.)  281. 

Veroual,  as  Hypnotic, Dangers  of,  435. 

-  Poisoning     from,     Value     in,    of 

Pituitrin,  319. 
Vertebrate     Hearts,     parts     minus 

Ganglion  Cells,  Action   on, 

of  Vagus,  66. 

Vertigo,  Labyrinthine,  423. 
Vessels,  see  Blood-vessels. 

-  of  Thebesius,  Maintenance  by,  of 

Circulation  after  Coronary 
Obstruction,  168. 

Vichy,  Potash,  or  Soda-water,  with 
Milk,  in  Rheumatic  Fever 
Diet,  372. 

Vienssens,  Annulus  of,  71. 

Viscera  (lee  also  Abdominal),  Cerebral 
Stimuli  from,  425. 

Viscosity  of  the  Blood,  how  Ascer- 
tained, Early  and  Later 
Experimenters  on,  146-7, 
Oxygen  to  Reduce,  Conse- 
quences of,  147. 

Vision,  Weakness  of,  from  Excessive 
Smoking,  827. 


Visits  of  Friends  to  Cardiac  Patients, 

Hints  on,  369. 
Visual  Centre,  Artery  to,  Contraction 

of,  Results,  185. 

-  Defects,  causing  Migraine,  183. 
Voluntary    Muscles,    E fleets   on,  of 

Drugs  in  Different  Doses,  275. 

-  -  Poisoned  by  Veratrine,  Heat  as 

affecting,  288. 

-  -  Rhythmical  Contraction  in,  how 

Induced,  88  n. 

Vomiting,  Caused  by  Retention  of 
Lactic  Acid  in  Stomach,  3S8. 

-  Centres,  Effects  on,  of  Toxic  Doses 

of  Digitalis,  298. 

-  Compression  of  Vagi,  to  Relieve, 

419. 

-  Continuous,   Blood-pressure    Low 

in,  181. 

-  of  Digitalis  Poisoning,  303. 

-  Headache  with,  Drugs  to  Relieve, 

448. 

WAKING  and  Sleep,  Alternation  of, 
Theory  of,  363. 

Walking  Exercise  in  relation  to 
Angina  Pectoris,  190 ;  in 
Xauheiin  After-cure,  249-50. 

-  Feat  of  Captain  Barclay,  5,  6. 

-  Uphill,  in  Oertel's  Treatment,  250, 

251. 

-  Upstairs  and  Down,  Strain  of,  on 

Heart,  232-3. 

Waller's  Investigations  on  Electric 
Changes  associated  with 
Cardiac  Movements,  139-45; 
his  System  of  Leads,  140,  and 
Method  of  Lettering  Electro- 
cardiograms, 142,  144. 

Warm  Baths  for  Insomnia,  427-8. 

-  Food,  to  Induce  Sleep,  255, 481 , 433. 

-  Poultice   over    Abdomen    in    In- 

somnia, 432. 

-  Water  Bags,  &c. ,  to  avert  Fatal 

Result  of  Chloral  Overdose, 

434. 
Warming  Cold    Feet,  Methods   and 

Precautions,  428-7. 
Warmth,  Bodily,  Maintenance  of,  in 

Raynaud's  Disease,  450. 
Waste,  Muscular,  Narcotic  products 

of,  863. 

-  Products,    13 ;    Effect   on    Frog's 

Heart,  285. 

-  -  Elimination    of,  Methods,    &c., 

238,  367,  375,  397-8,  403. 
Water,  Body's  Need  of,  385,  398,  how 
Best  Taken,  885-6. 


530 


INDEX 


Water  (eont.) 

-  and   Common    Salt,    in    Graves's 

Disease,  416. 

-  as   Diuretic,  348,    Action   of,   on 

Kidney  Circulation,  349. 

-  Exudation  of,  from  Liver  in  Venous   j 

Engorgement,  Results,  224,   j 
225. 

-  Iced,  in  Relief  of  Faintness,  423. 

-  of  the  Nauheim  Baths,  Nature,  and 

Uses,  244. 

-  Retention    or    Excretion    of,    in 

Urine,  Diet  as  affecting,  847. 

Water-Beds  and  Pillows,  Disadvan- 
tages of,  871-2. 

Water-waves,  Interference  of,  36-7. 

Waters,  as  Carminatives,  860. 

Wave,  Excitation,  Course  and  Effects 
of,  Gaskell  on,  68-9. 

-  Contraction,  in  Medusse,  85. 

-  Interference  of,  36-8,  (figs.)  86,  38. 

-  Reinforcing  each  other,  86,  (Jig.)  ib. 
Waxy  Pallor,  Facial,  in  Aortic  Re- 
gurgitation,  219. 

Weak  Heart  (see  also  iinder  Heart), 

Nauheim      Treatment     for, 

243  et sqq. 
Weakness,  Cardiac,  Dilatation  from, 

217. 
Weir-Mitchell  Treatment  in  Graves's 

Disease,  416. 
Wet  Cupping,  258. 
Wet  Pack,  Hint  on,  482. 
Whisky  in  Hot  Water  or  Milk,  as 

Hypnotic,  488. 
-for    Rheumatic    Fever    Patients, 

373-4. 


White  Corpuscles,  Course  of,  through 

Body,  9. 
Wind   in    the    Face,    why   causing 

Angina  Pectoris,  94. 
Women,    Apex-pain    in,   Cause   and      I 

Treatment,  188. 

-  Heat-flushes  of,  at  Menopause,  177. 

-  Plasters    over    Heart    for,    263, 

(ftg.)  ib. 

-  Slow  Pulse  of,  after  Childbirth,  107. 
Work  involved  by  getting  into  Bed, 

and  Going  Upstairs,  233. 
Worry,  Avoidance  of,  in  Low  Tension, 

451. 
Woulfe's     Bottle     for     Medicating 

Oxygen,  241,  242,  (fig.)  242. 
Wounds,  Linseed  Poultices  for,  266. 
Wright's  Method  of  Ascertaining 

Coagulability  of  Blood,  145-6. 


X-RAY  Examination  of  Heart,  138. 
-  Treatment  of  Pruritus  ani,  480. 
Xanthine,  288. 


YAWNING,  Vagus  Excitation  by,  419. 
Young  People,  Giddiness  in,  Causes, 
201. 


ZINC,  Valerianate  of,  for  Flushes  of 
Heat,  and  Blushing,  449. 

-  Sulphate,  Emetic  of,  for-  Paroxys- 
mal Tachycardia,  418. 

Zymogens,  Nature  and  Action  of,  891 ; 
Action  on,  of  Hormones,  893. 


INDEX  OF  AUTHORS 


NOTK  :  The  figures  in  italics  refer  to  Literature  at  end  of  each  chapter. 


ABDERHALDEN,  400. 
Ackermann,  SSO. 
Adami,  121, 113,  217,  SSO. 
Addis,  459, 1,60. 
Albanese,  173. 
Albert,  99. 
Albertoni,  400. 
Alexander-Lewin,  332. 
Allen  and  Hanburys,  241. 
Archangelsky,  455. 
Aubert,  23,  284,  291. 


BACCELLI,  195, 108. 

Bancroft,  97. 

Barclay,  SSI,  457. 

Barger,  98. 

Barlow,  SOS. 

Barnard,  104, 120. 

Barr,  459,  460. 

Basch,  von,  53,  65,  79,  82,  101,  102, 

105,  107,  119,  110,  123,  172,  182. 

207,  829,  SSI. 
Batelli,  399. 
Baum,  322. 
Baumann,  U6S. 
Baumgarten,  173. 
Bayer,  76,  83,  ISO,  261,. 
Bayliss,  23,  79,  82,  399. 
Begbie.  489. 
Bell,  460. 

Bergmann,  98,  26!,. 
Berkeley,  58,  79. 
Bernard,  18,  SS,  23,  89,  97,  291,  840-1, 

345,  397, 1,01. 

Bezold,  von,  17-4,  291,  299. 
Bidder,  26,  80,  31,  45,  56,  398. 
Biedermann,  US. 
Biedl,  293, 1,01. 
Blake,  295,  SSO. 
Bloebaum,  17f,. 

531 


Bock,  32S. 

Boehm,  S2 ,  344. 

Bdhme,  322. 

Bokeuham,  338,  345,  395,  kOO. 

Bond,  844,  345. 

Boruttau,  321. 

Bouchard,  368,  365. 

Bowditch,  85,  45,  56,  79,  267,  281,  2S2, 
290. 

Bowman,  846-7,  365. 

Bradbury,  459. 

Bradford,  J.  B.,  98. 

Braun,  321. 

Braune,  11, 12. 

Brodie,  194-5,  208. 

Brown-Sequard,  82,  98. 

Bruce,  89,  97,  121. 

Brticke,  154. 

Brunton,  1,  2,  6,  8,  9,  12,  14,  15,  20, 
22,  23,  27,  81,  33,  37,  41,  42,  47, 
49,  55,  67,  77,  78,  82,  83,  85,  8(1, 
87,  88,  92,  93,  94,  97,  98,  99,  105, 
106, 108,  109-10, 120, 121, 122, 123, 
127,  128,  181,  135,  147,  US.  151, 
154,  155,  157,  159,  160,  162,  165, 
170  <£«.,  171,  172,  174,  175,  179, 
181-2,  183-4,  185,  186,  187,  188, 
189,  191,  193,  195,  196,  197,  198, 
201,  202,  204,  206,  207,  208,  209, 
216,  217-8,  219,  221,  227,  228,  230, 
232-3,  236,  240,  241,  244,  254,  258, 
260,  268,  264,  265,  269,  270-1,  272, 
276,  290,  291,  293,  296,  304,  308. 
310,  814,  320,  321,  327,  829,  330. 
335,  836,  838,  841,  344,  345,  S4SJ 
850,  862,  364,  868,  869,  378,  876. 
377,  378,  379,  383, 888,  392, 396  n. , 
397,  400,  408,  407,  408,  410,  413, 
414,  415j  423,  482,  433,  489,  440, 
442,  445,  446,  450,  451,  458,  454, 
455,  457,  455,  459,  460. 


532 


INDEX  OF  AUTHORS 


Bruuton  and  Bokenbam,  338, 345, 395,   ' 

WO. 

Bruntou  and  Bowditch,  267. 
Bruuton   aud  Cash,  44,  45,  47,    ',9, 

270,  278,  281,  288,  292,  298,  817, 

3X0,  8*2. 

Brunton  and  Fayrer,  21,  it,,  221, 931. 
Bruntou  and  Gresswell,  888. 
Brunton  and  Krouecker,  112,  844. 
Bruuton  and  Meyer,  117,  12*,  299, 

320. 

Bruntou  and  Power,  804,  SSO. 
Brunton  and  Pye,  804,  806,  3?0,  SSI. 
Bruuton  and  Strieker,  !,5S. 
Brunton  aud  Tait,  386-8,  345,  459. 
Brunton    and   Tunnicliffe,  111,  112, 

Ml,  801,  802,  SSO. 
Brunton  and  Williams,  196,  208. 
Budge,  81. 
Bumke,  1*58. 
Bunge,  9S,  345. 
Burdon-Sauderson,  15,  S3,  44, 1,9, 139, 

14S. 
Burns,  194,  SOS. 

CABOT,  1S1. 

Cahii,  399. 

Cannon,  S99. 

Cantlie,  1,69. 

Carter,  258,  S65,  287,  293. 

Cash,  44,  45,  47,  49,  270,  278,  281, 

283,  292,  293,  298,  817,  SSO,  S22, 

330,  388,  3k&. 
Caton,  869-70,  S79. 
Cervello,  45S. 
Charteris,345. 
Chavalier,  345. 
Chischin,  398,  399. 
Cloetta,  406,  4.20. 
Colin,  68,  69,  SO,  St. 
Colmheim,  86,  J99. 
Colin,  22,  24. 
Collings,  75. 
Collingwood,  460. 
Cow,  23,  88,  97,  293,  SSI,  344,  345. 
Crile,  322. 
Cromaine,  98. 
Crum-Brown,  291. 
Cushny,  322,  40 1. 
Cybulski,  23,  293. 
Cyon,  23,  65,  SI. 
Czermak,  187  &n.,  208. 

DALE,  82,  98,  400. 
d'Arsonval,  98. 
Dartre,  23. 
Uavies,  965. 


Delezenne,  345. 

Demoor,  53,  79,  85,  96. 

Determann,  147,  149. 

Dickinson,  291,  330. 

Digne,  264. 

Dilling,  400. 

Dixon,  98,  275,  291,  459. 

Dogiel,  76,  230. 

Donaldson,  174. 

Bonders,  SI. 

Dreser,  293,  322,  1,58. 

du  Bois-Reymond,  117,  188,  186,  207. 

Dudgeon,  127,  128, 136, 11,8. 

Duke,  82,  293. 

Duncan,  147, 149. 

Dunstan,  330,  838,  345. 

Durham,  20S,  868,  365. 

Dusch,  von,  230. 

Dybkowsky,  22. 

ECKENSTEIX,  121. 

Eckhard,  46'. 
Edgren,  4,  4. 
Edkins,  399. 
Ehrllch,  280,  290,  292. 
Ehrmann,  97,  293. 
Eichhorst,  82,  160, 173. 
Einthoven,  189, 141  <t  n.,  1U8. 
Elliot,  321. 

Engelmaim,  46,  49,  56,  79. 
Erlanger,  59,  80,  115, 121, 169. 
Etienne,  261,. 
Eulenburg,  264,  330. 
Ewald,  18,  23, 147, 149. 

FAOOE,  Si'O. 

Faivre,  99. 

Fantino,  160, 175. 

Fayrer,  21,24,  221,231. 

Ferrier,  209. 

Fick,  90. 

Filehue,  291. 

Finkelstein,  24. 

Fischer,  1,18. 

Flack,  49,  57,  79. 

Fleckseder,  850,  365. 

Flourens,  61,  62,  SO. 

Forbes,  38  n. 

Franck,  17  n.,  81,  82,  173. 

Fraser,  291,  321. 

Frey,  von,  401. 

Friedliinder,  208,  863,  355. 

Froehlich,  45*. 

Frohlich,  53,  79, 82,  172,  322,  329,  331. 

G^RTSER,  108, 104,  120. 
Gamgee,  147, 149,  385,  336. 
Ganot,  S3. 


INDEX  OF  AUTHORS 


533 


Ganz,  89. 

Gaskell,  81,  32,  40,  47,  45,  56,  58,  68, 

70,  79, 81, 83, 98, 158,  nit,  293, 344. 
Gaultier,  345. 
-       Gautier,  tS. 
Generisch,  it. 
Gerhardt,  230. 
Gibson,  77,  80,  SS,  98,  115,  1*2,  171,, 

107,  S9S. 
Gierke,  62,  80. 
Glendinnlng,  76. 
Giiauck,  281,  282,  «92. 
Goltz,  45,  81, 178,  206,  907. 
Gottlieb,  80,  82,  291,  Stl,  SSS,  Skk, 

3,45,  848,  350,  365,  S99. 
Goulston,  253,  264,  287,  299. 
Greene,  293. 
Gresswell,  388. 
Griesinger,  174. 
Griiber,  S99. 
Griitzner,  S99. 
Gull,  98, 199,  200,  208. 
Gunning,  87. 
Gurboki,  81. 
Guthrie,  835,  345. 
Gattmann,  tSO. 
Guy,  174. 

HAFIZ.23. 

Haig,  452,  459. 

Hale,  76. 

Hales,  15,  SS,  146,  169. 

Haller,  22,  24. 

Halliburton,  t65. 

Hamel,  11,  33, 157,  240. 

Handler,  173. 

Hardie,  399. 

Harnack,  Stl. 

Haro,  147,  149. 

Harrison,  Boss,  200 n. 

Harvey,  2,  3,  7,  8,  20,  22,  186,  207. 

Hawksley,  110, 128. 

Hawthorne,  307. 

Hay,  338,  345. 

Haycraft,  99. 

Hedbom,  3!0,  322. 

Hehn,  331. 

Heidenhain,  23,  Ilk,  399. 

Heitler,  65,  81,  82. 

Henriques,  21. 

Hering,  174. 

Hermann,  45,  81,  83,  WO,  455. 

Herodotus,  231. 

Herrington,  131. 

Herschel,  49. 

Hesse,  75,  83,  215,  SSO. 

Heabner,  322. 

Hewlett,  174. 


Heymans,  53,  79,  85,  96. 
Hill,  3S,  81,  97, 102, 104, 130. 
Hirschfelder,  49,  115,  132,  US,  174, 

418,  457. 

His,  junior,  57,  59,  80, 143, 168. 
Hoffa,  79. 
Hoffmann,  S33. 
Hofmann,  A.,  45*. 
Hofmann,  F.,  33,  80,  81. 
Howell,  83,  97,  98, 174,  293. 
Huchard,  162, 174, 185,  308,  459. 
Hunter,  180, 189,  307. 
Hnrthle,  96. 
Husemaon,  291,  330. 
Hyderabad  Chloroform  Commission, 

227,  331. 

IMAGE,  207. 
Imchanetzky,  51,  79. 


J  A  ARSVBLD,  91  n. 

Jacquet,  127, 145. 

James,  SSO. 

Janeway,  106,  115, 120,  121, 

Janowski,  121,  321. 

Jenner,  195. 

Johannsen,  284,  293. 

Johnson,  9S,  200,  208. 

Jones,  Robert,  45S. 

Jones,  Wharton,  88,  97,  222,  231. 

Jonescu,  345. 

Joseph,  70  ». 


KALISCHER,  455. 

Kast,  455. 

Keith,  57,  79. 

Kent,  57,  50. 

Kobert,  330,  455. 

Kocher,  416,  457. 

Kochmann,  320. 

Koppe,  SSS. 

Korotkow,  113, 121. 

Koster,  51. 

Kratschmer,  S3,  306. 

Kraus,  82,  lS9&n.,  143, 144,  145,  149 

Kries,  von,  119, 122. 

Kronecker,  9,  11,  13,  21,  S3,  44,  49 
51,  60,  61,  62,  79,  50,  112,  121, 127 
145,  151,  173,  269,  282,  286,  290 
29S,  344. 

Kuhne,  22. 

Kunkel,  330. 

LAIDLAW,  52. 
Langenbacher,  24. 
Langendorff,  45,  272,  290. 


534 


INDEX  OF  AUTHORS 


Langer,  1,00. 

Langley,  291,  SSI,  330,  399, 1.01. 

Lee,  53,  64,  79. 

Leech  ,889,  345,459. 

Lewandowsky,  Sil. 

Lewin,  322. 

Lewis,  80,  139  n.,  165,  171,  171,. 

Liebreich,  434,  455. 

Lisfranc,  288. 

Lister,  8,  SS. 

Locke,  278,  287,  290,  293,  351,  36$. 

Loewi,320,  Sit,  345. 

Luciani,  281,  282,292. 

Ludwig,  7,  8,  11, 18,  15, 19,  If,  S3,  27, 
US,  52  <C  TO.,  66,  65,  76,  79,  81,  83, 
85,  87,  96,  119,  121,  122,  215,  230, 
267,  271-2,  277,  284,  290,  292,  530, 
883,  388,  344,  846-7,  365,  397,  Ml, 

Luff,  459. 

Lussatia,  1,00. 

MACALISTKR,  83. 

Macht,  459. 

Mackenzie,  58,  SO,  127,  136,  187,  US, 

174,  207,  ,400. 

M'Kenzie,  Tait,  215, 216, 230, 409,  410. 
Mackintosh,  379. 
Maclagan,  385. 
Macwilliam,  69,  80. 
Magendie,  76. 
Mager,  SSI. 
Magnus,  821,  SI,!,. 
Wall,  87,  97. 
Maly,  599. 
Marchand,  1,8. 
Maickwald,  21. 
Marey,  16,  23,  44,  49, 114,  191,  128-7, 

132, 135,  139, 11,8, 166,  171,,  330. 
Martin,  105,  121, 171,,  272,  290. 
Martindale,  365,  401,  455. 
Martius,  174,  293,  457. 
Marx,  2S1. 

Mayer,  A.  G.,  89,  39,  49,  St. 
Meibomius,  22,  24. 
Meilach,  265. 
Meltzer,  70  n. 
Mering,  von,  455. 
Merunowicz,  45,  292. 
Metchnikoff,  202-4,  20S,  858,  365,  480. 
Meyer,  A.  B.,  81, 117,  299-801,  320. 
Meyer,  E. ,  95. 
Meyer,  H.,  50,  52,  275,  279,  391,  292, 

345,  348,  850,  365,  399. 
Mills,  209. 
Moore,  399,  400. 
Morat,  23. 
Morison,  50,  207. 
Moritz,  399. 


Morro,  455. 

Mosso,  114, 121, 180,  207, 272,  M0,'34 

Miiller,  £.,  455. 

Muller,  J.,  24. 

Miiller,  O.,  23. 

Munk,  45. 

Murrell,  838,  345,  459. 

NICOLAI,  75,  52, 139  <Cn.,  148, 148,  W. 

145, 149,  173. 
Noorden,  von,  400. 
Nothimgel,  291. 

OKRTIL,  250,  264,  446. 

Oliver,  97,  95, 102, 118,  114,  119,  1*0 

121, 122,  321,  400,  443,  454, 1,0'.'. 
Osier,  174,  206,  207. 
Overton,  275,  291. 

PACHON,  115, 121. 

Page,  44,  49,  189, 145. 

Paget,  177  n. 

Pal,  195,  205. 

Pantelejelf,  282,  292.    • 

Parisot,  95. 

Parkes,  288,  293. 

Parry,  195. 

Paschutin,  22. 

Pa  ton,  400. 

Pawlow,  385,  395,  399. 

Pelouze,  291. 

Pembrey,  400. 

Percy,  275,  291. 

Pereira,  816,  322,  330. 

Pfliiger,  321. 

Pick,  401. 

Pickering,  298,  320. 

Pliny,  231. 

Poiseuille,  15,  22, 146, 149. 

Porter,  173. 

Potain,  102,  105,  107,  112,  120,  121 

445. 

Powell,  151. 
Power,  804,  320. 
Praag,  van,  330. 
Pratt,  173. 
Pribram,  52. 
Purkinje,  28,  45,  60,  67,  58,  75,  154, 

156, 173. 
Pye,  304,  306,1320,  321. 

Qi'AlN,  52  n. 
Qulncke,  399. 

RAMON  y  Cajal,  53,  79. 
Ransom,  291. 


Ranvier,  29,  47,  US,  56,  58,  79,  224, 

231,  310,  S21. 
Raynaud,  197, 198,  SOS. 
Recklinghausen,  vou,  108,  114, 121. 
Registrar-General  (1906),  SOS. 
Bemak,  26,  30,  47,  56. 
Uetzius,  53,  79. 
Reynolds,  414. 
Richardson,  335. 
Richet,  398. 
Rickett,  98,  SOS. 
Riegel,  172,  178,  ITU. 
Ringer,  273,  282,  285,  289,  390,  292, 

293,  SSI,  344. 
Ritchie,  1,57. 

Riva  Rocci,  104, 105, 108,  ISO. 
Robson,  460. 
Roever,  S3,  2k. 
Roger,  1,00. 
Rollett,  24. 

Romanes,  33,  34,  4S,  IS. 
Rosenberger,  U8. 
Rosenheim,  S93. 
Rosenthal,  330. 
Ross,  205,  209. 
Rossbach,  S91,  292. 
Rothberger,  400. 
Roy,  S3,  96,  HI,  11,8.  217,  230. 
(Russell,  111,  186,  207,  459. 
iRutherford,  83,  296,  296. 

-SADLKB,  121,  397, 1,01. 

-Sahli,  102, 114,  ISO,  121,  149,  SSO. 

Sainsbury,  331,  344. 

Scalfati,  314,  321. 

Schfifer,  97,  98,  11,9, 173,  SSI,  S2t,  399, 

400. 

Schapiro,  282,  292. 
Schierbeck,  399. 

Schiff,  23,  S9n.,  88,  97,  222,  SSO,  399. 
Scliliep,  SSO. 
Schmey,  61,  80. 
Schmidt,  398. 
Schmidt,  M.,  121. 
Schmidt-Muhlheim,  99,  400. 
Schmiedeberg,  49,  81,  91,  98,  270, 270, 

284,  £90,  291,  292,  203,  320,  321, 

330,  331,  340,  345,  45S. 
Schmulewitsch,  23. 
Scholtyssek,  US. 

Schott,  A.  &  T.,  243-4,  249,  250-1,  264. 
Schroeder,  von,  32S. 
Schomowa-Simanovskaia,  398. 
Schweigger-Seidel,  81,  85. 
Seligmann,  353. 
Senac,  22,  S/,. 
Setschenow,  S!. 
Sewall,  81. 


535 

Sharpey,  12, 187  n.,  295. 
Sherrington,  23. 
Simanowsky,  82. 
Somerville,  174. 
Stannius,  81,  40,  41,49. 
Starling,  79,  SS,  399,  400. 
Stefani,  79. 
Steger,  75. 
Stein,  399. 
Steiner,  81. 
Stevens,  208. 
Stevenson,  320. 
Stockmann,  545. 
Stockvis,  91  n.,  395,  400.  • 
Stokes- Adams,  168, 169. 
Strassburger,  115, 122. 
Straub,  292. 
Strehl,  97. 
Stretton,  264. 
Strieker,  87,  97,  45S. 
Sutton,  9S,  199,  200,  205. 
Symons,  82. 

TAIT,  37,  386,  S45,  459. 

Tawara,  27,  28,  31, 1,8,  57,  79,  SO. 

Thiry,  23. 

Thompson,  97. 

Thome,  U10. 

Tigerstedt,  59,  79,  SO,  81,  8S,  83,  97, 

98,  99,  US,  17S,  174. 
Tillie,  291. 
Timofeew,  160, 173. 
Tomaszewicz,  1,58. 
Traube,  82,  291,  295,  299,  320,  330. 
Tschermak,  81. 
Tunniclifle,  111,  112, 121,301,  302,  SSO. 

VALSALVA,  172,  228. 
Vaquez,  174,  264. 
Vieussens,  71. 
Vincent,  97,  293,  401 
Voegtlin,  459. 
Vohl,  330. 
Voit,  399. 
Vulpian,  88,  97. 

WACHENFELD,  330. 

Waller,  4,  4,  16,  18,  S3,  67,  SI,  139, 

140,  140,  142,  144,  145.  149,  419, 

457. 

Walpole,  98 
Wassilieff,  81, 160, 173. 
Weber,  39,  49. 
Weir-Mitchell,  416,  457. 
Weiss,  97. 
Wells,  97. 

Wenckebach,  169, 174. 
Wertheimer,  23,  345. 


INDEX  OF  AUTHORS 


Westcott,  SCH,  1,01,  i,£S. 
White,  Hale,  1,57. 
Wiedemann,  Si2. 
Wiener,  895,  ItOO. 
Wiggers,  U)l. 
Wilkinson,  83. 
Willcox,  658. 
WillianiB,  C.  J.  B.,  76. 
Williams,  F.,  209,  290. 
Williams.  W.  E.,  190,  !08. 


Winterberg,  WO. 
Wintermitz,  t65. 
Witkowski,  St2. 
Womack,  111. 
Wood,  S91. 

Wooldridge,  69,  80,  81. 
Woulfe,  241. 
W'right,  145,  ll#,  UB9. 

XIBOLER,  173,  202,  SOS. 


' 


PRINTED  BY  OLIVER   AND   BOYD,    EDINBURGH,   SCOTLAXD. 


L  005  493  309  8 


A    001375541    8 


